1907 The Lancet  
734 from the lymphatics of the legs escaped into the bladder. There was no inflammation in the urinary tract and the kidneys were normal. Purulent pericarditis, hypostatic pneumonia, and acute bronchitis were present. This was the fourth published case of a necropsy on a patient with non-tropical chyluria. There were strong reasons for believing that all cases of chyluria, whether due to iilarise or not, were caused by the same anatomical abnormality-viz., obstruction to the thoracic duct or
more » ... ge abdominal lymphatics, with consequent dilatation of abdominal and pelvic lymphatics and rupture of a dilated lymphatic into the urinary tract. The obstruction in filarial chyluria appeared to be due to a fibrous stenosis of the thoracic duct, secondary to inflammation brought about by the presence of filariae at some earlier period. The parasites themselves had never been found blocking the thoracic duct. As the obstruction, when once produced, would be permanent it would remain after the niarias had all died out. Hence cases, such as the present one, in which the patient had been abroad 20 years before the onset of the chyluria, might quite well have been due to an old infection with niarise which had completely died out, leaving the obstruc. tion in the thoracic duct. Presumably the rupture of a dilated lymphatic into the -bladder occurred only in March, 1906. In non-filarial cases the obstruction was probably due to some other parasite, or more frequently to caseous glands or other tumour pressing on the duct from without. Hence the distinction between tropical and non-tropical chyluria was artificial and not warranted by the pathogenesis of the two conditions. Mr. T. M. HAMELL said that he had made observations on a subject in which chyle came from a chylous fistula. The rate of appearance of fat in the chyle was dependent on the condition of the fat and whether it had a high or low melting point. The fats with a low melting point appeared more rapidly than those with a high melting point. He had never been able to detect dextrose in the chyle. He asked whether by any operation it was possible to connect the part of the thoracic duct below the lesion with that above it. Dr. HERTZ, in reply, said that he had made no experiments with regard to the rapidity of absorption of the fats with the high or low melting points, but for the ordinary fats of food it took only half an hour before they began to appear in the urine. Exercise increased the lymph flow and the rapidity with which the fat appeared in the urine. Ormond-street, and gave an analysis of the 39 cases which had been observed at that hospital since 1897, 35 of which had been males. The age at which vomiting had commenced varied ; out of 37 cases noted four had commenced at birth, three at one week, nine at two weeks, 11 at three weeks, five at four weeks, two at five weeks, two at six weeks, and one at eight weeks of age. These and other facts threw doubt upon the condition being a congenital defect. Other congenital malformations were notably absent, and the condition did not recur in other members of the same family. Hypertrophy of the pylorus and gastric peristalsis had been detected in all Dr. Voelcker's cases. In regard to the pathology it had been suggested that such cases consisted of a pyloric spasm caused by excess of hydrochloric acid, and Dr. Voelcker was of opinion that the pyloric lesion was secondaty to some alteration in the gastric secretion. Out of 39 hospital cases 34 had died. Five of Dr. Voelcker's seven cases had been operated upon, all of whom had died. He attributed the recovery of the other two to lavage and diet. He did not think surgical intervention of any form was advisable. Mr. F. F BuRGHARD read a paper on the Surgical Treatment of Congenital Pyloric Stenosis, based upon 16 cases that had come under his own care. Five years ago operative treatment was strongly advocated but of late professional opinion had undergone considerable change. His opinion was that only in a small proportion of cases was operation indicated. He pointed out that the chief difficulty at present was to know in what proportion of cases medical treatment alone might be expected to suflice. Whereas in former years most of the cases came under the surgeon's hands at an early date, the tendency at present was to delay operation as long as possible in the hope that medical measures alone would succeed. This hope was justified in a certain number of cases and the debate would probably do much practical good by enabling surgeons to form some idea of results that were likely to follow medical treatment alone, as hitherto no extended experience had been published. Dealing with the question of operative results, 16 cases in all had been operated upon by the same method-namely, dilatation of the pylorus. Of these cases 11 had recovered satisfactorily from the operation, ten remaining well, whilst one case died within three months of the operation from convulsions ; the operative mortality was, therefore, 31' 25 per cent., whilst the total mortality was 37' 5 per cent. The chief danger of the operation was shock, which could be minimised by careful preliminary preparation and operating rapidly in a well-warmed room, never less than 70° F. ; 25 minutes should be mfficient, ten being occupied in the dilatation. Two accidents that had happened in the series of cases quoted were rupture of the pylorus (in two cases) and wound of the duodenum (in one case). These accidents could be treated by immediate suture and were not necessarily fatal. Dilatation of the pylorus was preferable to pyloroplasty but this last was preferable to gastro-jejunostomy. The chief danger of dilatation was splitting the pylorus and to obviate this the incision into the stomach should not be made too near to the pyloric orifice. No recurrence of symptoms occurred after any of the cases quoted. Dr. HEXRY ASHBY (Manchester) said that he had made necropsies on about 11 cases. He had been struck by the marked hypertrophy, though it rarely caused complete obstruction, but he could not help thinking that the hypertrophy was not the essential cause. There were always a large quantity of mucus and other evidences of gastric catarrh. This condition was probably antenatal and produced an over-action of the sphincter which led to the hypertrophy. It was difficult to make out a hypertrophied pylorus during life but with a little patience the abdominal walls might relax and the pylorus drop down from beneath the liver. All his cases had improved temporarily under lavage and small quantities of thin food such as whey. Only one of his cases had been operated upon and the patient had died 12 days later. Mr. CLINTON T. DEXT agreed that the results of surgical intervention had not been very favourable. Out of about 120 collected cases, including a number of unpublished ones, that had been operated on the mortality was about 50 per cent. Unfortunately, surgeons rarely saw these cases until an advanced stage had been reached. Pyloroplasty or pylorectomy was preferable to gastro-enterostomy; the former certainly restored the functions of the pylorus. He had in his possession a section from the pylorus showing that the hypertrophic condition was most certainly antenatal. Prolonged medical treatment certainly jeopardised the surgeon's treatment. Dr. G. F. STILL said that he had observed 27 cases. Out of 23 in which the result was known 14 had recovered completely : eight of these had been operated on, five of them having been mild cases which had been passed on directly to the surgeon : the other six had been treated medically, five by lavage and one by dieting only. Of the nine that died three were untreated, three were operated on, and three were treated medically. Thus the results were practically as good by medical as by surgical treatment, but each case must be judged on its own merits, not by statistics. He took exception to Mr. Dent's statement as to the undue severity of the cases sent to the surgeon as compared with those treated medically, and he raised the question as to the later results of operative measures. On the other hand, three or four months' persistent lavage was a serious undertaking. Mr. G. H. MAKINS had operated on two cases and the patients had both recovered, though one had died later from enteritis. Dr. EDMUND CAUTLEY thought that these cases could be differentiated into three classes: (1) pure pyloric spasm without evidence of hypertrophy, attended by vomiting of
doi:10.1016/s0140-6736(01)55393-3 fatcat:yh5gmic2jfbhffktnolakmzrge