A system of practical medicine. By American authors. Vol. 4

by Unknown

¹⁰ Trans. Path. Soc. of London, vol. xxxiii. p. 394, 1882.

That a chylous urine is the direct result of a discharge of chyle into the urinary passages at some point between the kidney and the neck of the bladder, is further rendered likely by the experience of W. H. Mastin of Mobile, Alabama, with a case of chylous hydrocele: W. H. W., a native of Alabama, aged twenty-two, presented himself with a hydrocele. Mastin tapped the sac and drew off a white milk-like fluid, which was sent to me for examination. It was perfectly white and undistinguishable by the eye from milk. Upon microscopical and chemical examination, I found it presented all the physical and chemical characters of chyle. Six months later, the sac having refilled, Mastin evacuated eight ounces more of the same fluid—some of which was again sent to me—and then laid open the sac freely. Examining the cavity carefully, he found it smooth, polished, and pearly white, but at its upper portion, just where it began to be reflected over the testis, was a small, round, granular-looking mass about the size of an ordinary English pea. This he sliced off with a pair of scissors, and at once recognized the patulous mouths of three or four small vessels which did not bleed. These he dissected back for a short distance, and found that they passed into the connective tissue around the upper border of the testis. He then passed a ligature around the mass and brought the ends of the ligature to the outside, excised all the front wall of the tunica, and closed the sac. The patient recovered, and there was no return of the hydrocele. Although it is to be regretted that the patulous vessels were not watched for a few minutes, I do not think there can be any reasonable doubt that there was here a lymphatic varix, and that the chylous fluid in the tunica was the result of leakage through its walls. Since the patient had had gonorrhoea, Busey,¹¹ in his remarks on this case, suggests that the obstruction to the onward movement of the lymph, and the cause, therefore, of the dilatation and rupture, was inflammation attacking a single gland or an area of lymphatics.

¹¹ Occlusion and Dilatation of Lymph-Channels, by Samuel C. Busey: A series of papers reprinted for private distribution from the New Orleans Medical and Surgical Journal, from Nov., 1876, to March 1878.

If it be acknowledged, then, that in chyluria some direct communication must exist between the lymphatic and urinary systems, how is this communication brought about? Various causes have been supposed at different times to be responsible for this condition, among them traumatism in its various modes of occurrence, such as being thrown from a horse. Mental shock has also been held responsible. So, also, syphilis and hereditary tendency. But most cases still remained unaccounted for when, on August 4, 1866, Wücherer first detected in the chylous urine of a woman in the Misericordia Hospital at Bahia an unknown worm. In 1872 it was announced that Timothy R. Lewis had found in the blood, and also in the urine, of a person suffering with chyluria in Calcutta, a delicate thread-like worm about ¹/70 of an inch long and ¹/3500 of an inch wide. This observation was confirmed by Palmer and Charles. Lewis named it Filaria sanguinis hominis. Since then the filaria has been found in the blood and urine of many cases. Lewis found six in a single drop of blood from the ear, and estimated 700,000 as approximately correct for the whole body. But Mackenzie calculated that there were in the blood of his patient from 36,000,000 to 40,000,000 embryo filariæ. These minute nematodes, discovered by Wücherer and Lewis, proved to be, as was indeed early suspected, the larvæ of a larger filaria which was discovered by Bancroft of Brisbane, Queensland, Australia, in December, 1876, first in a lymphatic abscess in the arm, and afterward in the fluid of hydrocele of persons infested with the smaller worm. The parent worm is about the thickness of a human hair and three or four inches long. It was named, by Cobbold, Filaria Bancrofti. Lewis himself found, in August following, a male and female of the parent worm, in a scrotum infiltrated with chylous fluid, in a case of elephantiasis. The female contained ova with embryos precisely like those found in the blood and urine. The worms are viviparous, but abortions seem frequent, ova being frequently discharged unhatched.

It has been rendered highly probable, by the researches, first, of Manson in China, and later of Lewis in India and Sonsino in Egypt, that the filaria in its fully-developed form is introduced into the stomach and intestines of man with water. Thence it makes its way into the blood and lacteal system, where it reproduces the embryo filariæ. These embryonic or larval filariæ are taken from the human blood by a mosquito, in the body of which it undergoes further development, after which the perfect Filaria Bancrofti is deposited in water, through which it again reaches the stomach of man, and thus the disease is perpetuated.

One of the most singular features in the history of the filaria is its nocturnal habit. It is found in the blood only at night, unless, as Mackenzie has shown, night be converted into day—that is, if the hours of sleeping and waking be reversed. In Mackenzie's case the worms appeared about seven o'clock in the evening, increased up to midnight, and disappeared by eight or nine o'clock in the morning. What becomes of them at the time when they are undiscoverable in the blood is as yet unknown.

Acknowledging filariæ to be the essential cause of chyluria, the precise method in which they operate to cause the obstruction, dilatation, and rupture of the lymphatics is a matter of speculation. The embryo filariæ are so lithe and small that they move among the corpuscles apparently without harming them, but the ova in which the embryos lie coiled up, and which are often discharged unhatched, are large enough to cause obstruction in the smaller lymphatics and lymph-passages of the lymphatic glands, and thus cause the phenomena of chyluria, as well as of the other diseases of the lymphatic system with which it is often associated, or which may occur independently of it, such as elephantiasis, cutaneous lymph-vesicles with their chylous and lymphous discharges, lymph scrotum, chylous hydrocele, and other diseases of the lymphatics. Indeed, the total number of affections other than chyluria which are found associated with filariæ exceed those of chyluria. Among the diseases with which it is said to be associated is erysipelas.

It is evident, therefore, that notwithstanding the fact that the discovery of the Filaria sanguinis hominis has shed a flood of light upon the subject of chyluria, the fact must not be overlooked that not a few cases of the disease have occurred in which the most careful search has failed to find this parasite in the blood. Careful examinations, during waking and sleeping hours, have been made without result, so that we cannot deny altogether the possibility of the disease occurring independent of filariæ as the cause. It is common, therefore, to speak of parasitic and non-parasitic chyluria.

On the other hand, the filaria embryo is often found in the blood of persons apparently in perfect health. Manson tells us that out of every ten Chinamen taken at random, at Amoy, the blood of one will contain filariæ.