The Effusion of Chyle and of Chyle-like, 
Milky, Fatty, and Oily FEids into 
the Serous Cavities. 
BY 
SAMUEL C. BUSEY, M. D., LL. D., 
Of Washington, D. C. 
FROM 
THE AMERICAN JOURNAL OF THE' MEDICAL SCIENCES, 
December, 1889. Extracted from the 
American Journal of the Medical Sciences for December, 1889. 
THE EFFUSION OF CHYLE AND OF CHYLE-LIKE, MILKY, 
FATTY, AND OILY FLUIDS INTO THE SEROUS CAVITIES.1 
By Samuel C. Busey, M.D., LL.D., 
OF C. 
The object of this paper is to present the subject of effusion of chyle, 
chyle-like and fatty fluids into the serous cavities. It will be limited to 
the consideration of the effusion of such fluids into the cavities of the 
pleurae, peritoneum, and tunica vaginalis. 
Traumatic injuries of the absorbent vessels seem to have been a sub- 
ject peculiarly attractive to many of the older authors. Ruysch, as 
early as 1665, drew attention to wounds of the lymphatic vessels, and 
refers to a certain surgeon " who had, unfortunately, cut a lymphatic 
vessel in incising a venereal bubo not completely developed, from which 
flowed daily a great quantity of lymph." Solingen, in 1693, reported 
two cases of " lymph fistulie situated at the head of the soleus muscle, 
one consequent upon a wound, the other produced by contortion of the 
limb." Muys, in 1695, saw a young man who had been wounded in the 
left external malleolus, and from the wound " there flowed every day a 
vast quantity of water." Nuck, in 1733, wrote of wounds of the lym- 
phatic vessels. " Very often," he says, " in venesection performed on 
the arm, and especially when performed on the foot, the absorbent 
vessels are injured; by carelessness in regard to these vessels the lancet 
has proved fatal." Van Swieten, in 1764, recorded the observation that 
frequently most abundant discharges of lymph followed venesection; 
and Haller, a few years later (1773), stated that he had known a " flux 
of lymph of such long continuance, and so difficult to arrest, that he 
could explain its existence only upon the supposition that a large vessel" 
had been severed in bloodletting. Mascagni and Assalini, in 1787 
cited cases of lymphorrhagia following venesection ; the latter mentions 
the case " of a boy, eleven years old, who lost five pints of lymph in 
three days from a slight wound located upon the internal part of the 
thigh." Soemmerring (1795) and Monro also recorded observations of 
discharges of lymph following slight wounds; and Schreger (1799) 
mentions an instance of lymph fistula following bloodletting in the foot. 
'Read before the Association of American Physicians, Washington, September, 1889. 2 
BUSEY, EFFUSION OF CHYLE. 
Soemmerring remarks that the healing of wounds on the instep, near 
the ankles and knees, on the back of the hands, near the bend of the 
elbows, and near all joints, is impeded by the continual dripping of 
lymph, and offers the explanation that, as the " absorbents about the 
joints are protected only by very thin skin and very little fat," the 
swelling and inflammation which ensue prevent contraction and com- 
pression of the incised vessels. In 1817, Nasse recorded several instances 
of lymph fistulae caused by traumatic lesions of lymph vessels; in some 
of the cases he analyzed the fluid discharged and proved it to be lymph.1 
Since then lymph fistulse from traumatism seem to have attracted but 
little attention, though quite a large number of cases of lymphorrhoea 
and lymphorrhagia, occurring in consequence of diseased conditions of 
some portion of the lymphatic system, have been carefully recorded. 
Subsequent to the discovery of the chyliferae of the dog by Aselli; 
of the lymphatics in the intestines of man by Gassendi; of the recep- 
taculum and thoracic duct by Pecquet; and of the lymphatic trunks of 
the extremities by Rudbeck, and about the time when the works of 
Ruysch, Meckel, Hewson, Mascagni, Cruikshank, and Hunter ap- 
peared, there were reported very many cases of chronic ulcers with 
fistulous openings, from which a fluid was discharged which the observers 
believed to be lymph. Even as late as 1859, Binet maintained that 
neglected lesions of lymph vessels would give rise " to ulcers of the most 
rebellious character," and suggests that ulcers of the lower extremities 
very frequently owe their origin "to alterations of the lymphatic 
vessels." Such ulcers may be recognized, says Binet, " by the abun- 
dance of the matter excreted, compared to the extent of the ulcer; by 
the increase of the excreted fluid when gentle pressure is made from the 
extremity toward the lesion ; by the exceptional difficulty in cicatriza- 
tion, and by the nature of the excretion." During the same period- 
previous, however, to the publication of the investigations of Mascagni, 
Cruikshank, Hunter, and Hewson-there were also a number of cases 
of " milky discharges " recorded. These were evidently cases of copious, 
and, perhaps, somewhat modified, purulent secretions. The instance of 
" milky saliva " reported by Antonio Nuck,2 and the case of " milky 
1 M. Nelaton has three times met with dilatation of lymph vessels at the fold of the 
elbow, on a level with the cicatrices of bleeding. 
2 "Practicus observed saliva evidently milky. For a woman, he says, nursing a 
child, again became pregnant, and therefore weaned the child. The right breast, from 
neglect, became like a large tumor, and on a certain night subsequently, while suffering 
much pain, she had an abundant discharge of milk from the mouth, with a correspond- 
ing decrease of the swelling in her breast. She swallowed the milk as it came into her 
mouth (without any inconvenience), which continued for four months." 
"But it may be asked, how came the decrease in the breast? In my judgment in no 
other way than this, that the masses of the blood were laden with chyle, the particles 
of which could not permeate the lactiferous tubules of the mammas on account of their BUSEY, EFFUSION OF CHYLE. 
3 
discharge from the cutaneous surface of the abdomen " reported by 
Rommel,1 are the most authentic of these curious cases. Among these 
dubious cases may also be enumerated the case of Schurig,2 of a milky 
discharge from a wound; the case of fistulous communication with cold 
abscesses or deep-seated suppurating glands;3 from the uterus, by 
Dolaeus ;* from the tunica vaginalis ;5 and from the mucous membrane of 
the nose, by Richter.6 
Assalini relates (Binet) having seen, during many months, discharged 
from the neighborhood of the umbilicus, in two women recently delivered, 
a fluid which he believed to be of lymphatic nature. Both women 
succumbed to puerperal accidents. When Assalini wrote (1787), the 
lymphatics were being studied, and it is probable that he accepted con- 
clusions without verification, as did Soemmerring after him, who, perhaps, 
mistook various collections of pus for metastases of milk. Puzos,7 whose 
conception of the pathology of puerperal diseases seems to have been 
limited to the supposed formation of depots of milk in various parts and 
tissues, reports several cases in which collections of milk were found in 
the abdominal cavity. In one instance he found a " gallon of coagulated 
milk," the patient having died of fever five days after delivery of a dead 
foetus. 
The view held by Puzos, and by others previous to his time, that milk 
was formed from the food of pregnant women and passed commingled 
with the blood throughout the system, being determined, during gesta- 
tion, to the uterus to nourish the foetus, and to the breast, after delivery, 
to nourish the infant, led very naturally to the conclusion that a super- 
abundant supply or deficient consumption would eventuate in the forma- 
tion of depots of milk in other localities. 
collapsed condition, but formed a tumor in those nearest the mammary gland, especially 
since their arteries were filled and were not capable of removing any more. Indeed, 
the chylous and milky particles were abundantly distributed through the blood mass, 
and permeated the glandular structures, especially the salivary, which offered the least 
resistance. In the meantime, the blood, on account of its freer and quieter motion, pro- 
pelled the chylous particles remaining in the breast toward the veins, and thus to the 
heart; hence it followed the breast was emptied." Sialographia, etc., Ductuum Aquoso- 
rum Anat. Nova. Lugduni Batavorum, 1695, p. 49. 
1 "A woman who was nursing twins began to complain, a few days after the death 
of one of them, of a sense of dull pain and tension beneath the ribs of the right side of 
the abdomen and over the umbilicus. This feeling was succeeded by stretching, the 
stretching by itching, and the itching by an exudation of fluid from the skin, the 
color, taste, and consistence of which were identical with milk, and which yielded a true 
butter on agitation." Ephemerides Germanise, decur ii., ann. viii. 
2 Parthenolopia, Dresden or Leipsig, 1729. 
3 Med. Essays and Obser., by a Society in Edinburgh, vol. 5, part 1, p, 328. 1747. 
4 Ephem. Germ., decur ij., ann. vj., obs. 76. 
5 Madras Quarterly Journ. Med. Sei., vol. 1, p. 180. 
6 Med. and Surg. Obser., Transl. Ed., 1744. 
7 Memoirs sur le lait npander, on depots laiteux. New edition, Paris, 1801. P. 141. 4 
BUSEY, EFFUSION OF CHYLE. 
It is probable that the cases of Bossu, Martin, and Milleret (7, 8, and 
10) belong to this class of reports; nevertheless the case of " particular 
dropsy" first observed by Poncy in 1699, was undoubtedly a case of 
hydrops chylosus. The description of the morbid appearances presents 
so many conditions so closely analogous to those found in the case re- 
ported by Marshall Hughes in 1841 (17) that the apparent vague state- 
ments must be attributed to the imperfect knowledge of the reporter, 
rather than to his fancy. 
Frequency.-The reported cases of effusion of chyle and'milk-like fluids 
into the pleural and peritoneal cavities, including the doubtful cases, 
may not exceed sixty-three, and these reports cover a period beginning 
with Policy's case in 1699 and terminating with the reports of the cases 
of Drs. Smith and Newcomb, of New York-one hundred and ninety 
years. Their infrequency relegates them to the category of patho- 
logical curiosities. Nevertheless, thirty-nine of the cases of effusion and 
collection of chyle and chyle-like fluids in the abdominal cavity have 
been observed during the present century; thirty-four of these cases since 
1850, and twenty-seven during the last and present decades. The in- 
creasing frequency of occurrence is thus clearly shown. For whilst the 
more numerous reports during these decades may, in some measure, be 
due to more accurate observation and careful study of morbid anatomy, 
yet it is not prdbable that such remarkable cases would have escaped 
the observation of intelligent physicians at any period since the time of 
Poncy, Morton, Monro, Scherb, Percival, and Sandifort. 
The increasing occurrence of the cases of effusion of milk-like and 
fatty fluids into serous cavities is more clearly shown by the numerous 
recent reports of cases of lymphocele by Manson. Lewis, and Sonsino 
and in this country by Mastin, Sr. and Jr., and Guiteras. Whether or 
not this fact is attributable to the more extended habitation and fruitful 
propagation of the intermediate host of the filaria sanguinis hominis now 
known to be constantly associated with, if not the cause of lymphuria 
and lymphocele, is a problem of great interest and graver import. 
Effusion into the Pleural Cavities, Chylo-thorax. 
There have been, including the doubtful cases, ten reports of cases of 
injury produced either by disease or accident, either of the thoracic duct 
or some of its larger affluent branches, in the thorax, sufficient to emit 
fluid in quantities incompatible with vigorous health, and certainly en 
dangering life, if not causing death. In five of these cases, the chyle 
poured directly from the duct, in one of which (Bassius) the aperture in 
the walls of the vessel was not suspected until discovered at the autopsy 
In the cases of Hoffman, Guiffiirt, Bonet, and Quincke the rupture or 
the duct was the result of external violence. The case of the learned 
mathematician, reported by Hoffman, was probably a case of empyema. BUSEY, EFFUSION OF CHYLE. 
5 
and the case of the Baron de Heinden, reported by Bonet, who was 
injured by a missile in the battle of Fionensis, is doubtful, though Bar- 
tholinus, to whom the details of the case were communicated, expressed 
the opinion that the thoracic duct was injured. In Curling's case the 
lymph concretion, which occupied the right pleural cavity, was discovered 
in the body of a patient whose right lower extremity had been ampu 
tated at the hip-joint, ten months before his death, for malignant disease 
of the thigh. The concretion consisted of " softened and degenerated 
lymph." There was no evidence of malignant disease or " secondary 
deposits in any of the organs." In the cases of Rokitansky and Ormerod 
(see 23 and 25 of tabulated statement) chyle was found in the pleural and 
peritoneal cavities; in the former the effusion was the result of obstructed 
heart circulation, and in the latter the result of the interruption of the 
blood current in the left subclavian vein. In two of the cases reported 
by Quincke (28 and 29) chylous fluid was found in the pleural and peri- 
toneal cavities, though the post-mortem examination determines the cases 
as one of " effusion of chyle into the peritoneal cavity," and the other an 
" effusion of chyle into the right pleural cavity." In both cases the 
anatomical lesions were clearly made out; in one the duct was lacerated 
within the thorax, and in the other, chyle retention was caused by in- 
flammatory thickening of both folds of the mesentery. Some of the 
lacteals were completely, others partially occluded. The chyle vessels 
were injected exactly to the union of the intestines with the mesentery. 
The flow of chyle was impeded, engorgement of the vessels ensued, and 
rupture occurred. But how explain the presence of chyle in-the peri- 
toneal cavity in Case 29 and in the pleural cavity in Case 28 ? In 
each instance the phenomenon is perhaps partially explicable upon the 
hypothesis that portions of the effused fluid traversed the lymph vessels 
of the diaphragm. In the case of Pelletier, the chylothorax and chylous 
ascites were associated with a milky diarrhoea and the vomiting of a 
milky fluid. 
The cases in which fatty and oily fluids, other than chyle, have been 
found in the pleural cavities have not been included in this collection of 
cases of chylothorax. A number of such cases have been reported by 
Herard, Bacelli, Gueneau de Mussy, Quincke, Debove, and others. 
Quincke characterizes such fluids as effusions of chyle; Gueneau de 
Mussy as altered pus; and Debove as chyliform fluids, but specific 
effusions distinct from serous, purulent, or serofibrinous exudations. The 
clinical histories and morbid appearances associate such cases with tuber- 
culosis and cancer, and determine the inflammatory nature of the exu- 
date. In none of these cases has there been discovered any solution of 
continuity of chyle or lymph vessels. 
With the exception of the cases of Rokitansky, Ormerod, and one of 
Quincke, all the cases of effusion of chyle into the pleural cavities belong 6 
BUSEY, EFFUSION OF CHYLE. 
to a class of casualties which do not admit of any generalization, and 
are only instructive in suggesting the occurrence of an improbable con- 
tingency, which may happen under circumstances very various. 
The diagnosis of chylothorax cannot be made except by evacuation 
and examination of the fluid. In Quincke's case of injury by crushing 
of the chest wall, the effusion was not suspected until discovered by 
aspiration of the fluid. The prominent symptoms in such cases are 
dyspnoea and the accumulation of fluid in one or both cavities. In a 
single instance chyle was discharged drop by drop through a puncture 
in the chest wall. The prognosis is unfavorable and the treatment ex- 
pect i nt. 
Effusion of Chyle-like or Milky Fluid into the Cavity of the 
Tunica Vaginalis Testis : Galactocele, Chylous Hydrocele, 
Chylocele, LymphoceLe, Milky Hydrocele, Lymphous Hydro- 
cele, Filarial Hydrocele. 
The case of galactocele reported by Vidal (de Cassis) seems to have 
been the first observation of this class of effusions. Ruthnum's case of 
hydrocele, " with contents simulating chylous urine," was published in 
1864 ; and Ferguson's case of " milky fluid from the tunica vaginalis " 
in 1865. Neither of these cases attracted any special attention, and 
their reporters seem to have regarded them as curiosities. In Vidal's 
case the fluid consisted of water, a substance resembling albumen, sugar, 
chloride of sodium, traces of lime, and numerous globules having the 
appearance of the globules of butter. In Ruthnum's the fluid looked 
like milk, and in Ferguson's case it consisted of a colorless fluid in 
which floated very many globules and a number of minute and large 
cells not unlike colostrum corpuscles. In each case the fluid coagulated 
spontaneously. Neither Ruthnum nor Ferguson refers to the case of 
Vidal, and probably did not know that Lebert, as early as 1855, had 
suggested that the case of Vidal was nothing more than the rupture of a 
" lymphatic varix into the cavity of the tunica vaginalis." 
Previous to these reports varices had been frequently observed in the 
superficial and deep-seated integumentary lymphatic vessels and plexuses, 
but very rarely, if at all, in the capillaries and plexuses of the serous 
membranes. Morton, in 1689, and Mascagni, in 1787, observed varices 
of the pulmonary lymphatics ; Caldani, in 1761, described a varix of the 
lymph vessels of the heart; Wathen, in 1787, and Sandifort, in 1780, 
recorded cases of dilatation of the lymph vessels the small intestine. 
In the latter case the varix resulted from obstruction of the lacteals, 
caused by intussusception. Soemmerring observed the dilatation of the 
lymphatics of the duodenum and of the intestines in hernise. He also 
refers to instances in which he had seen the lymphatic vessels of the 
liver and spleen " filled with a whitish material," and Lebert asserts BUSEY, EEFUSION OF CHYLE. 
7 
that he had frequently observed dilated lymphatics on the surfaces of the 
liver and lungs. Schreger and Tilesius saw a case of dilatation of the 
lymph vessels of the conjunctivae. 
The fourth case in chronological order was reported by C. H. Mastin 
(1874), of Mobile, and to him is due the credit of verifying the sugges- 
tions of Lebert. After an examination of a specimen of the fluid 
obtained at the first tapping, I called the attention of Dr. Mastin to this 
suggestion, and in his second operation in April, 1875, he " opened the 
sac freely for a distance of two or three inches " and discovered, at the 
upper portion of the membrane, where it begins to be reflected over the 
testis, " a granular-looking mass," which having beeu snipped off was 
recognized by him to be the " patulous mouths of three or four small 
vessels," which he believed were "portions of lymph vessels." In 1881, 
in a similar case, Dr. W. M. Mastin practised the same procedure and 
discovered a varix similarly located, but when cut off showed the 
patulous orifice of only a single vessel, from which lymph exuded. 
Specimens of fluid from both of these cases were carefully examined by 
Dr. James Tyson, who described them as comparable to chyle in their 
chemical and physical characters, and expressed the belief that they 
found exit into the sac through rupture of a lymph vessel. 
These two observations made by our own countrymen, in the city of 
Mobile, seemed to have established the nature of lymphocele. But, in 
the meantime, Lewis had discovered the filaria sanguinis hominis, and 
quite a number of cases of lymphocele, lymphuria, and elephantoid 
diseases had been reported by Manson, Lewis, Sonsino, and others, in 
which this parasite was recognized as the probable, if not the constant 
and positive cause. In this country, since the beginning of 1885, there 
have been reported thirteen cases in which the filaria were found, two of 
which were cases of lymphocele. The first in 1886 by Guiteras, in the 
city of Charleston, and the other in 1888 by Mastin, in the city of 
Mobile. Manson ascribes elephantoid diseases to embolism of lym- 
phatic glands by the ova of the filaria, stasis, and consequent regurgita- 
tion of lymph. If this be true, it is not improbable that the varicose 
and ruptured lymph vessels of the tunica vaginalis in cases of lympho- 
cele are the result of gland obstruction produced by similar emboli. It 
has not been shown, however, that filaria are present in every case of 
lymphocele. It is conceivable that adenitis, gonorrhoeal lymphangitis, or 
other conditions which obliterate the permeability of neighboring and 
connecting glands might cause stasis of lymph and dilatation and rupture 
of lymph capillaries and plexuses, with which the serous membranes 
are so richly supplied. Vidal vaguely hinted that a previous gonorrhoea 
was the cause in his case; and Mastin, in a review of the previous 
cases, assumed, in 1883, that chylocele was due to " obstructed gonor- 
rhoeal lymphangitis." Since the discovery of the filaria in the third 8 
BUSEY, EFFUSION OF CHYLE. 
case occurring in Mobile, he has modified his opinion, and hints at a 
classification of causes into filarial and inflammatory obstruction of 
lymph-glands. Sonsino asserts that the theory of mechanical obstruc- 
tion caused by the adult worm in the lymphatic channels, with all its 
consequences, as lymphangitis, lymphatic dilatations, rupture, and con- 
sequent lymph extravasation or external lymphorrhagia " is sufficient to 
explain all the morbid disorders or diseases which have been associated 
with the worm, and may be originated by it, as lymphuria and lympho- 
cele." The matured opinion of those who have had the best opportuni- 
ties of studying the relation of the filaria to diseases in general seems to 
accept the statement of Sir Joseph Fayrer that " it has been shown that 
disorders of the lymphatic system are most frequently associated with, 
if not caused by, the filaria." Guiteras asserts that " manifestations of 
filarial disease may all be included under the head of disturbances 
of the lymphatic circulation." This view meets with opposition from 
Rake, who failed to find filaria in cases of elephantiasis and chyluria 
examined by him in Trinidad. 
The chemical and physical properties of the fluid emitted in lympho- 
cele characterize it as a pathological product. Simple dilatation and 
rupture of a lymph channel, plexus, or space would not necessarily give 
exit to a fluid so rich in fat and other products. 
The recent invasion of portions of the sub-tropical belt of this country 
by the filaria, and reports of cases of disease with which the parasite has 
been so uniformly associated, together with the fact that the mosquito 
has been proven to be its intermediate host, present considerations of the 
highest importance to the profession and general public. 
The diagnosis of lymphocele depends upon the ordinary symptoms of 
hydrocele and opacity of the tumor, but the character of the fluid can 
only be ascertained by observation and chemical and microscopical 
examination. Vidal noted the absence of translucency. It may be that 
the general symptomatology of filarial disease coexisting with the col- 
lection of fluid in the tunica vaginalis might suffice to determine the 
presence of parasitic lymphocele, but neither of the cases observed in 
Mobile seems to have presented such a clinical picture and history. 
The case cited by Guiteras was associated with commencing elephantiasis 
of the scrotum. 
Ruthnum cured his case by injections of iodine. Mastin dissected 
back the varix for a short distance and " tied the bundle en masse, with 
a small and very strong silk ligature." Mastin, Jr., practised the same 
procedure. In both cases the cure was complete. BUSEY, EFFUSION OF CHYLE. 
9 
Chylous, Chyliform, and Oily Ascites. [Hydrops Chylosus : 
Hydrops Adiposus. J 
The accompanying tabulated statement, arranged chronologically, 
presents a brief and condensed summary of the reports of the cases of 
chylous and oily ascites. A rigid analysis would exclude many from 
the category of chylous ascites. The cases of Bossu, Martin, Milleret, 
and Sandifort, which occurred in puerperal women, are so closely allied 
to the views of Puzos, previously referred to, that they must be accepted 
cum grano satis. In two of the cases there was no extravasation into 
the peritoneal cavity, one of which was a chylous cyst of the mesentery, 
and the other a case of chyle retention in the chyle vessels of the mesen- 
tery. In several of the cases (18,19, 21, 27, and 34) the fluid was more 
oily than chylous and coexisted with tuberculous peritonitis, which would 
more properly characterize the fluid as a morbid exudation than an 
effusion of chyle. In three of these five cases the ascites was ascribed to 
obstructed pulmonary circulation, one of which (18) had suffered for a 
long time with chronic bronchitis, with " purulent expectoration con- 
taining tuberculous concretions another (27) suffered for several years 
with scrofulous affections and died of pulmonary tuberculosis; and the 
third (21) died of pulmonary and peritoneal tuberculosis. Excluding 
the puerperal and tuberculous cases, together with the two in which no 
extravasation was found in the peritoneal cavity (50 and 53), the cases 
of chylous ascites proper will not exceed twenty-eight. In Case 37, Prof. 
Winiwarter ascribed the intra-abdominal effusion to " congenital occlu- 
sion of the thoracic duct, formation of a compound cystic tumor through 
distention of the lacteals at the root of the mesentery by obstructed chyle, 
rupture of one of the cysts before or during birth, persistency of this 
solution of continuity, and increasing effusion of chyle." In twenty-seven 
cases the rupture of some chyle-conveying vessels seems to be clearly 
established. 
Etiology.-Age is an unimportant element of causation. The ages of 
the twenty-eight cases vary between birth and sixty-two years. Fifteen 
were females, the oldest sixty-two and the youngest at birth. The ages 
of the eleven males ranged between two and sixty-one years. If the 
puerperal and tubercular cases be included, sex assumes a more important 
etiological relation, and the proportion would be two females to one male. 
Race, climate, occupation, and circumstances of life are without influence. 
Hereditary and acquired tendency to diseases of the lymphatic system, 
and especially disease of the walls of the thoracic duct and receptaculum 
chyli, which are very rare and mainly limited to tuberculous infiltrations 
and ossific changes, demand mention as primary conditions which may 
facilitate the rupture of the walls of chyle-conveying vessels; syphilis 
may also. Primary rupture occurred in but five of the cases. In one 
* 10 
BUSEY, EFFUSION OF CHYLE. 
No. 
Reporter. 
Date. 
Where reported. 
Sex. 
Age. 
Causative conditions. 
Treatment. 
Results. 
1 
I'oncy, Jr.1 
1699 
Saviard, Observations in Surgery, 
trans, by Surgion, p. 247 Bond. 
F. 
18 
Obstruction of lymph glands and vessels. 
Medicines and tapping, 
Died. 
2 
R. Morton,2 
1705 
Morton's Phthisiologia, Lib. i., 
chap. x. 
M. 
2 
Compression of duct, near subclavian vein, by large 
tumors behind "trachea arteria," producing rupture 
of lacteals. 
Tapping. 
Died. 
3 
Littre, 
•1710 
Mem. de 1'Acad. des Sci. 
F. 
7 
Enlarged aud chalky mesenteric glands. 
Not stated. 
Died. 
4 
Chomel, 
1728 
Mem. de 1'Acad. des Sci. 
F 
24 
Rupture at umbilicus third day after confinement, with 
discharge of five pints of milky fluid; supposed rup- 
ture of abdominal lymphatics. 
Counter-opening. 
Recovered. 
5 
6 
J. G. Scherb, 
Donald Monro,2 
1729 
1765 
Haller, Dissertatio Abmorborum, 
vol. iii. p, 237. 
Essay on Dropsy. 
M. 
F. 
39 
Calculus in receptaculum ehyli. 
Effort to "raise a burthen." 
Tapping. 
Tapping. 
Died. 
7 
Bossu, 
1770 
Journ. de Med. Chir. Pharm., 
xxxiv. p. 283. 
F. 
Metastasis of mammary secretion during first week of 
puerperium. 
Tapping, purgatives, and 
resolvent applications 
to abdomen. 
Recovered. 
8 
Martin, 
1770 
Journ. de Med. Chir. Pharm., 
xxx. p 555. 
F. 
Metrorrhagia; miscarriage; unusual exercise. 
Tapping 
Recovered. 
9 
Targioni, cited by 
Bianchi,3 
1771 
Lo Sperimentale, Ivii. p. 78, 1886. 
F. 
21 
Obstinate chlorosis; imperfect chylification due to pres- 
sure of lymphatics by enlarged spleen. 
Tapping, purgatives, de- 
obstruents, corrobor- 
ants, diuretics, cardiac 
tonics, mercury. 
Recovered. 
10 
Milleret, 
1774 
Journ. de Med. Chir. Pharm., 
xlii. p. 237. 
F. 
39 
Arrest of secretion from mammary glandsand intestinal 
canal. 
Spontaneous discharge at 
umbilicus, and tonics. 
Recovered. 
11 
Joseph Lieutard, 
1779 
Historia Anatomica Medica, t. i. 
p 257. 
7 
Mesentery cirrhosed and filled with a whitish, chalky 
substance ; large quantity of milky or chylous fluid 
in abdominal cavity. 
Not stated. 
Died 
12 
Lossinm, cited by 
Lieutard, 
1779 
Historia Anatomica Medica, t. i. 
p. 257. 
Child 
"Abdominal cavity filled with a milky fluid, evidently 
derived from ruptured chyliferous vessels." 
Not stated. 
Died. 
13 
Ed. Sandifort, 
1781 
Observ. Anat. Patholog., Ludg. 
Bat., iv. 1-21, 3 pl. 
F. 
Following premature birth of twins at seven months. 
Sandifort reports another case of lacteal metastasis to 
abdominal cavity. 
Effusion only discovered 
at autopsy. 
Died. 
14 
Percival,2 
1788 
Essays, Med., Physiol., and Exp., 
ii. p. 177. 
F. 
8 
Rupture of lacteals. 
Tapping. 
Recovered. 
15 
Weaver, 
1814 
Med., Surg., and Pharm. Repos., 
ii. p. 377. 
M. 
Protracted illness, supposed to be liver disease, 
Mercurials and other 
medicines. 
Died. 
16 
Truman Abell, 
1833 
Boston Medical and Surgical Jour- 
nal, vii. p. 13. 
F. 
Abdominal tumor following pregnancy with twins. 
Spontaneous rupture at 
umbilicus with dis- 
charge. 
Died. 
1 First tapped by Poncy July 2, 1699. Died in 1770, after twenty-second tapping ; amount of fluid withdrawn 285 French pints. 
2 Essay on Dropsy and its Species, by Monro, third ed., p. 22. London, 1765. 
3 Bianchi cites three cases from Mehu, but without details; probably cases of chyliform ascites. 
Cases of Chylous, Chyliform, and Oily Ascites arranged Chronologically. 11 
No. 
Reporter. 
Date. 
Where reported. 
Sex. 
Age. 
Causative conditions. 
Treatment. 
Results. 
17 
Hughes, 
1841 
Guy's Hospital Reports, v. p. 297. 
M. 
30 
Tumor of agglomerated mesenteric glands; numerous 
lacteals were large, tortuous, varicose, and distended 
with milky or clear fluid. 
Not stated. 
Died. 
18 
Van Camp, 
1843 
Ann. Soc. de Med. de Anvers, ii. 
M. 
59 
Chronic bronchitis, asthma, tuberculosis. 
Not stated. 
Died. 
19 
J. Popham, 
1854 
p. 86. 
Dublin Quarterly Journal of Medi- 
cine, xvii. p. 467. 
F. 
28 
Chronic peritonitis, with fat in the effusion ; fatty de- 
generation of liver; free fat in blood; fatty contents 
of both ovaries combined with hair and bony matter. 
Not stated. 
Died. 
20 
M. Lorain, 
1859 
Compt. Rend. Soc. de Biol., Par 2, 
s. v. 162. 
F. 
8 
Symptoms analogous to those of tubercular peritonitis; 
numerous tubercles in lungs. 
Not stated 
Died. 
21 
T. Stevenson, 
1860 
Guy's Hospital Reports, 3 s., xvii. 
p. 231. 
Report refers only to the composition of two specimens 
of milky fluid obtained from abdomen in two cases. 
Not stated. 
22 
Oppolzer, 
1861 
Allg. Wien. med. Zeitung, S. 149. 
F. 
42 
Mitral and tricuspid insufficiency; thoracic duct plugged 
at,outlet with pale and red fibrous coagula; walls thick- 
ened ; lumen dilated with thrombi. 
Not stated. 
Died. 
23 
Rokitansky, 
1861 
Patholog. Anatomy, Bd. ii. S. 388. 
F. 
6 
Dilatation of heart; thickening and shortening of mi- 
tral valve; occlusion of thoracic duct with soapy 
material. 
Not stated. 
Died. 
24 
W. Cayley, 
1866 
Trans. Path. Soc. Lond , xvii. p. 
163. 
M. 
19 
Fibrinous vegetations attached to intima of subclavian 
vein ; partial obliteration of thoracic duct near its out- 
let ; rupture of receptaculum. 
Not stated. 
Died. 
25 
Ormerod, 
1868 
Trans. Path. Soc. Lond., xix. p. 
199. 
M. 
24 
Left subclavian and its affluent branches plugged with 
a light colored and ragged clot. 
Tapping. 
Died. 
26 
Hoppe-Seyler, 
1873 
Arch. Gesammte Phys., vii. p. 407. 
Rupture of chyle vessels from pressure of a tumor. 
Not stated. 
27 
Bergeret, 
1873 
Journ. d'Anatomie, t. ix. p. 585. 
F. 
27 
Scrofula; pulmonary tubercle; oily ascites. 
Not stated. 
Died. 
28 
Quincke, 
1875 
Archiv f. klin. Med., Bd. xvi. S. 
128. 
F. 
30 
Flow of chyle obstructed by inflammatorj thickening of 
folds of mesentery and transformation of adipose into 
connective tissue 
Tapping. 
Died. 
29 
Quincke, 
1875 
Archiv f. klin. Med., Bd. xvi. S. 
121. 
M. 
50 
Run over by a wagon. Rupture of thoracic duct; effu- 
sion into peritoneal and pleural cavities. 
Tapping. 
Died. 
30 
Quincke, 
1875 
Archiv f. klin. Med., Bd. xvi. S. 
121. 
F. 
33 
Primary cancer ot peritoneum ; fluid containing fat 
globules and fat cells; hydrops adiposus. 
Not stated. 
Died. 
31 
Quincke, 
1875 
Archiv f. klin. Med., Bd. xvi. S. 
121. 
F. 
10 
Scrofulous glands, and tuberculosis; fluid milky and 
fatty; hydrops adiposus. 
Not stated. 
Died 
32 
Friedreich, cited by 
Quincke, 
1875 
Archiv f. klin. Med., Bd. xvi S. 
121. 
F. 
12 
Scrofula and miliary tubercle ; milky fluid, with fat 
and fatty cells ; hydrops adiposus 
Not stated 
Died. 
33 
Pelletier, 
1875 
Journ. de Med. Chir. Pharm , 
Ixiii p. 496. 
F. 
Chylous fluid vomited ; also found in peritoneal and 
pleural cavities. 
Tapping. 
Recovered. 
34 
Wilhelm, 
1875 
Corres.-Blat. d.Aerztlichen Vereine 
d. Rhen prov., No. 14, p 13. 
2 mos. 
Abdominal tumor firmly attached to spinal column in 
umbilical region ; rupture of thoracic duct. 
Tapping, first at two 
months. 
Died. 
35 
Ballman, 
1876 
Centralbl. f. d. med. Wissensch.. 
xiv., p. 274. 
F. 
39 
Peritoneum closely studded with tubercle. 
Tapping. 
BUSEY, EFFUSION OF CHYLE. 12 
BUSEY, EFFUSION OF CHYLE. 
No. 
Reporter. 
Date. 
Where reported. 
Sex. 
Age. 
Causative conditions. 
Treatment. 
Results. 
36 
F. Winckel, 
1876 
Archiv f. klin. Med., Bd. xvii. S 
303. 
F. 
39 
Puncture of chyle vessels by parasites. Had lived in 
Surinam. 
Tapping; lived four 
years. 
37 
Winiwarter, 
1877 
Jahrbuch. f. d. Kinderheilkunde, 
v. xi. Nos. 1, 2, and 3. 
F. 
Birth 
Rupture of chylous cyst; probable occlusion of thoracic 
duct and dilatation of lacteals. 
Careful alimentation and 
tapping. 
38 
Kein, 
1881-2 
Mem. Soc. de Med. de Strassburg, 
xix. 2, 52, 57. 
F. 
50 
Rupture of mesenteric and intestinal lacteals. 
Tapping, each time four 
gallons of milky fluid. 
39 
Smidt,with permis- 
sion of Guttman, 
1881-2 
Zeitschrift f. klin. Med., p. 199 
M. 
11 
Chronic idiopathic peritonitis. 
Tapping. 
Died. 
40 
Veil, 
1882 
Paris ThiSse, 21. 
F. 
25 
Syphilitic gummata of liver; fluid chylous and rich in 
fat globules with few leucocytes. 
Not stated. 
•Died. 
41 
Gaucher, cited by 
Veil, 
1882 
Paris These, 21. 
M. 
47 
Cirrhosis of liver ; milky and containing fat. 
Not stated. 
Died 
42 
Gaucher, cited by 
Veil, 
1882 
Paris Thfese, 21. 
M. 
39 
Hard drinker; cirrhosis of liver; fluid first two tappings 
ordinary, afterward milky and fatty. 
Not stated. 
Died. 
43 
Gaucher, cited by 
Veil, 
1882 
Paris These, 21. 
11 
Sarcoma of omentum and mesentery ; enlarged and 
degenerated mesenteric glands. Thoracic duct normal. 
Not stated. 
Died. 
44 
Whitla, 
1883 
Brit. Med. Journ., vol. i. p. 1089, 
1885. 
M. 
13 
Peritoneum and pleurae studded with miliary tubercle ; 
liver and lungs infiltrated with miliary granulations; 
mesenteric gland enlarged, forming tumor; thoracic 
duct occluded at middle third, dilated at lower third, 
with perforation at lowest part; receptaculum dilated 
and perforated. 
Tapping; 117% pints 
withdrawn in three 
months 
Died. 
45 
F. Nickerson, 
1884 
Mass. Med. Soc., June, 1884. 
M. 
56 
Chylous cyst; probably continuous hard labor. 
Tapping. 
Recovered. 
46 
Lettule, 
1884 
Revue de Med., iv. p. 723. 
M. 
3 mos. 
Congenital cardiopathy and chronic peritonitis, with 
cough; probably syphilis. 
Tapping and digitalis. 
Improved. 
47 
Lettule, 
1885 
Revue de M5d., iv. p. 9C0. 
M. 
8 
Rheumatism involving heart; enlarged liver and spleen; 
fluid milky, containing granules, leucocytes, and fat 
globules. 
Not stated. 
Died. 
48 
Strauss, 
1886 
Arch, de Physiolog. et Patholog. 
M. 
61 
Peritoneal cancer, perforation of chyle vessels on an- 
terior surface of mesentery. 
Tapping; diet of milk 
and butter. 
Died. 
49 
P. J. Murphy, 
1886 
Pamphlet. 
F. 
19 
Violence ; long and fatiguing walks and dancing. 
Laparotomy. 
Recovered. 
50 
N B. Carsun, 
1889 
Medical News, Iv. p. 52. 
M. 
39 
Chylous cyst of mesentery. 
Laparotomy and removal 
ot cyst 
Recovered. 
51 
Stephen Smith, 
1889 
Personal communication. 
M. 
9 
General health fair; no cause discovered, 28 pints of 
fluid evacuated in 21 days; rich in lymph cells, few 
blood corpuscles, slightly acid ; specific gravity 1015. 
Tapping and drainage 
tube. 
Under ob- 
servation 
52 
J. E. Newcomb, 
1889 
Personal communication. 
M 
2 
Previous health good ; no cause discovered ; fluid milky, 
containing lymph cells. 
Tapping. 
Under ob- 
servation. 
53 
Weichselbaum,1 
Virch. Archiv, Ixiv. p. 145. 
M. 
89 
No extravasation, but stasis of chyle in the chyle ves- 
sels of the mesentery and hypertrophy of the inter- 
posed adipose tissue. 
Discovered at autopsy. 
Died. 
1 Case of chylangioma cavernosum. BUSEY, EFFUSION OF CHYLE. 
13 
(6) the cause was " an effort to raise a burthen in two (45 and 49) 
muscular effort; one vomiting ; and one violence inflicted upon the chest. 
In eleven cases the rupture or perforation was demonstrated, and in six- 
teen others the character of the fluid left no doubt of its escape from a 
chyle-conveying vessel. 
Chylous ascites may be the secondary result of a variety of morbid 
conditions which directly or remotely obstruct the flow of the chyle 
through the lacteals, receptaculum, or thoracic duct, impede its exit 
into the left subclavian vein, or retard the current of blood in the left 
subclavian vein, right side of the heart, or lesser circulation. Such 
obstruction may be caused by anatomical defects and anomalies of 
position and distribution of the chyle vessels, by dilatation or stenosis, 
and such disease of the coats of these channels as would lessen their 
expansibility and tensile strength; by disease of the mesentery, hyper- 
trophy, cavernous and fibroid transformation of its adipose tissue ; by 
indurated, degenerated, and impermeable mesenteric glands, embolism, 
and deposits of bony, chalky, gelatinous, and soapy material in the 
channels; compression by inflammatory adhesion or by thoracic, ab- 
dominal, and aneurismal tumors. In one case it was ascribed to the 
presence of the filaria. 
Dilated chyliferous lymphatics are quite often observed in the mesen- 
tery. The usual cause (Zeigler) is obstruction due to inflammatory or 
neoplastic growths located in the mesentery or thoracic duct. Some- 
times the obstruction is due to lymph thrombosis. The dilated vessels 
look like straight cylindrical ridges, or convoluted, saccular, or beaded 
cords; their contents are either white and limpid or pulpy and caseous. 
In three cases (5, 24, and 43) the aperture through which the chyle 
escaped was found in the wall of the receptaculum ; in one the perfora- 
tion resulted from ossification of its wall and filling of the cavity with 
a bony concretion; and in No. 24, in consequence of stenosis of the 
thoracic duct, near its outlet. In five cases (1, 2, 14, 17, and 28), and 
probably in 23 and 26, the rupture took place in the lacteals. In four 
of these cases, and in the cases of Hoppe-Seyler, Abell, and Wilhelm 
(16, 26, and 34)-in which no post-mortem examination was made, 
abdominal tumors were discovered, either by inspection of the cadaver 
or by palpation during life. In two cases the thoracic duct was com- 
pressed by tumors located near its entrance into the left subclavian 
vein. These tumors were usually glandular, and consisted of hypertro- 
phied and degenerated bronchial or mesenteric glands coexisting, in two 
instances, with cancerous formations. 
In Cases 23 and 25, the chylous effusion into the peritoneal cavity 
was attributed to interrupted venous blood current in the subclavian 
and innominate veins ; and in Cases 2, 17, and 24 to stenosis of the 
thoracic duct at or near its entrance into the left subclavian vein. 14 
BUSEY, EFFUSION OF CHYLE. 
Clinical1 observations seem to have established the causal relation of 
interrupted blood current in the large veins near the heart to lymph 
stasis and effusion of chyle into the peritoneal cavity, and the experi- 
ments of Cooper, Morton, Dupuytren, and others demonstrate that com- 
plete arrest or interruption of the current of the fluid in the thoracic 
duct, at or near its terminal extremity, will, if the anastomotic circula- 
tion is not speedily and sufficiently established, produce distention, 
dilatation, and repletion sufficient to cause rupture, which most fre- 
quently takes place in the receptaculum or lacteals. Clinical and post- 
mortem observations are even more conclusive than experimentation, 
for they connect directly the process of gradual occlusion of the duct by 
disease with the concurrent development of a diffuse area of lymphan- 
giectasia, which in some cases terminated in rupture and extravasation. 
In this connection may be cited the cases of Rokitansky, Ormerod, 
Morton, Hughes, and Cayley enumerated in the tabulated statement, 
and other cases which I have collated in a contribution to the American 
Journal of the Medical Sciences, vol. xc. p. 373. 
The force exerted upon the contents of the thoracic duct by the pass- 
ing current of blood in the subclavian vein is nothing more than an 
illustration of the hydraulic principle of Venturi, but the explanation of 
the relation of cause and effect between cardiac disturbances and lymph 
stasis and chyle effusion must, in a general way, be sought in the vary- 
ing conditions of blood pressure. Niemeyer2 asserts that "obstructive 
engorgement of the great veins extends to the thoracic duct," and Hertz 
says an over-distended left subclavian vein will not permit the adequate 
emptying of the thoracic duct.3 
The relation of the .puerperal conditions to the effusion of chyle are 
not susceptible of explanation. The theory of metastasis of the secretion 
of the mammary glands is untenable. In Sandifort's case the uterus and 
vagina were lined by a pseudo-membrane, which was not detachable; in 
Martin's case the evacuated fluid resembled whey; in Milleret's case the 
fluid was at first white, "of the consistency of clear bouillon," afterward 
gelatinous and offensive, and, finally, soap-like and odorless. Subse- 
quently the patient suffered with lymphatic engorgement of the lower 
extremities and lumbar region, but finally regained her health. In the 
case reported by Bossu the secretion of milk was so abundant that appli- 
cations were made to suppress it, which were entirely successful ; then 
followed the accumulation of milky fluid in the abdomen, which having 
been evacuated, "the milk returned to the breast," and no reaccumula- 
tion followed. Three of these four patients recovered. The occurrence 
1 Busey: The Causal Relation of Obstructed Cardiac Circulation to Lymph Stasis. 
American Journal of the Medical Sciences, vol. xc. p. 373. 
2 Text-book of Practical Medicine, vol. i. p. 120. 
3 Ziemssen's Cyclop., vol. v. p. 382. BUSEY, EFFUSION OF CHYLE. 
15 
of lymphatic oedema in Case 10 is the only circumstance in the clinical 
reports of these cases suggestive of such a diagnosis, but it is insufficient 
to justify the classification of the case in the category of chylous ascites. 
The case reported by Chomel is analogous to the case of Truman Abell, 
and is worthy of a more favorable consideration. "A puerperal woman, 
aged twenty-four years, after suffering for several days with a swelled, 
tender, and painful abdomen, was suddenly awakened during the night 
by the pouring out of a milky fluid through a rupture of the umbilicus. 
Five pints of fluid were lost." Chomel ascribed the accumulation of fluid 
in the abdominal cavity to rupture of lymphatic vessels. 
Pelletier's patient (33) was seized with chylous vomiting and diar- 
rhoea, and a chylous fluid was withdrawn by tapping from the pleural 
and peritoneal cavities. This case was reported in 1875, at a period 
when a mistake in diagnosis ought not to have been made; nevertheless, 
the causal relation of the vomiting and diarrhoea to the extravasation 
of a similar fluid into the serous cavities is not apparent. Sprague 
reports a "fatal case of vomiting of a chyle-like fluid," but there was no 
effusion into either of the serous cavities. Chyle may be vomited and 
discharged per mum, and it is not impossible that in rare instances the 
effort at vomiting might rupture some chyle-conveying vessel. 
In nine cases the fluid found in the peritoneal cavity was associated 
with tuberculosis, in four of which it is distinctly stated that the peri- 
toneum was more or less studded with tubercle. The fluid in these 
cases was very rich in fat, albumen, and chlorides. Perforation or rup- 
ture of a chyle-conveying vessel was discovered in two of the cases. 
They were reported as cases of milky or oily ascites, and their clinical 
histories picture the ordinary symptomatology of either pulmonary or 
peritoneal tuberculosis. 
In some of the cases of chyliform ascites, in which no solution of con- 
tinuity of chyle and lymph channels could be discovered, the fluid 
consisted of an inflammatory product mixed with lymph and chyle. In 
such cases the chyle and lymph must have escaped by transudation. 
This conclusion is the more probable in view of the facts that in some 
of these cases the changed condition of the coats of the vessels was such, 
together with the partial or complete obliteration of the lumen of the 
thoracic duct or smaller channels, either by the thickening of-their walls 
or by the lodgement of morbid products, that transudation of lymph and 
chyle might take place in quantities sufficient to impart to the coexisting 
inflammatory product characteristics easily distinguished by the ordinary 
methods of physical, chemical, and microscopical examinations. 
In another form of chyliform ascites, as for instance the cases of 
Whitla and Straus, in which the fluid was not unlike that found in the 
cases above referred to, but containing a larger proportion of chyle and 
lymph, the admixture of chyle and an inflammatory product was clearly 16 
BUSEY, EFFUSION OF CHYLE. 
demonstrated by the coexistence of tuberculous peritonitis or cancer, and 
the discovery of one or more perforations in the walls of the chyle or 
lymph vessels, through which chyle and lymph escaped. In several of 
such cases there was also discovered more or less obstruction to the flow 
of chyle through the thoracic duct, and, consequently, increased pressure 
in the receptaculum, lacteals, and lower part of the duct, where rupture 
almost always take place. 
In that form of chyliform ascites more properly and usually denom- 
inated adipose or oily ascites, in which the lymph and chyle channels, 
lymph-glands, lacteals, and mesentery are intact and free from disease, 
distention, pressure, or obstruction, and normal in structure, size, and 
position, which must exclude the effusion of lymph or chyle by transu- 
dation or escape through solution of continuity in any part of the lymph 
system, the milky, fatty, chyle-like, and opalescent fluid must necessarily 
be a morbid product. The fluid in this class of cases varies somewhat 
in appearance, but more markedly in the proportions of fatty matter. 
Gueneau de Mussy asserts that all such cases are simply cases of chronic 
tuberculous, cancerous, or neo-membranous peritonitis, which is probably 
true, with, perhaps, a single exception. That exception refers to the 
case of Guttman, reported by Smidt, in which the cause is ascribed to 
a " chronic idiopathic peritonitis." 
Whilst, therefore, in most cases of chylous and in some cases of chyli- 
form ascites, there is either rupture or perforation of a chyle-conveying 
channel, transudation through attenuated, diseased, and degenerated 
walls cannot be excluded as a cause. In the chyliform varieties transu- 
dation is the most frequent and important element of causation, because 
of the more constant presence of morbid conditions of the walls of such 
channels. 
It must, then, be admitted that these forms of ascites are more fre- 
quently due to some lesion of the lymphatics than to any other cause. 
Nevertheless it is true that ascitic fluid may be milky or chylous in 
appearance without containing any chyle or lymph. Letulle and Gue- 
neau de Mussy believe that the lactescent color of such fluids is due to 
the fatty degeneration of the white blood-corpuscles. 
Symptomatology and Diagnosis.-The symptomatology of effusion oi 
chyle into- the peritoneal cavity is not sufficiently distinctive to differen- 
tiate such cases from those of ordinary ascites. Wounds of chyle-con- 
veying channels might be diagnosticated by the location and direction 
of a stab or puncture, in connection with the escape of chyle into the 
pleural or peritoneal cavities or externally through the aperture, or its 
evacuation. As such effusion can only occur through transudation or 
solution of continuity, its escape externally, or presence in either cavity, 
must be essential for differential diagnosis. If no fluid escapes externally, 
then only the symptoms of a fluid accumulation in the cavity are present, BUSEY, EFFUSION OF CHYLE. 
17 
the character of which must be ascertained by evacuation and examina- 
tion. 
The quantity of chyle which may escape by transudation through 
the walls of normal vessels is small, and the accumulation is neither 
rapid nor continuous. When it escapes through an aperture in the 
walls of some channel the opposite conditions are present. Hence an 
effusion of chyle might be suspected when a rapid accumulation of 
fluid in the peritoneal cavity should be associated with sudden loss 
of appetite, acute emaciation and anaemia, rapid prostration, dimin- 
ished secretion of urine, and the presence of such conditions as would 
suggest occlusion, stenosis, or compression of the thoracic duct, or 
arrest of the exit of the chyle into the subclavian vein. The gradual, 
partial, and progressive compression of the thoracic duct has been 
frequently determined by the location of a tumor, associated with 
evidence of blood impoverishment. In uncomplicated cases due to rup- 
ture (Cases 6, 48, 49), " the patient, usually after exertion (Murphy), is 
suddenly seized with sharp, localized pain, followed by swelling of the 
abdomen," anuria, anorexia, nausea, and, possibly, vomiting. In most 
cases the symptoms are complicated with those of the causative condi- 
tion, and a diagnosis is only possible by an examination of the evacuated 
fluid. In no instance has a diagnosis been made previous to observation 
of the fluid. 
In the chyliform varieties the symptomatology is even more variable, 
because of the presence of the symptoms of the concomitant visceral 
lesion. 
In some cases of suspected leakage of chyle the diagnosis may be 
verified by experimental feeding. In Poncy's case the odor of some 
articles of diet was recognized in the evacuated fluid; and in the case 
reported by Straus the proportion of fat in the fluid more than doubled 
during the exclusive milk and butter diet. 
Prognosis.-Of the 53 tabulated cases, 33 died, 10 recovered, and in 7 
cases the result is not stated. 3 of the puerperal cases recovered,, and 
all the tubercular cases died. Of the 10 recoveries, 8 were females and 2 
were males. Of the 28 cases of chylous ascites proper, 15 died, 6 recov- 
ered, and in 5 cases the result is not stated. Of the 5 recoveries, 4 were 
females and 2 males. In whatever aspect the cases may be considered, 
the prognosis is unfavorable. The larger number of cases were females, 
and the larger proportion of recoveries were of the same sex. The female 
sex, therefore, exhibits greater liability to, and a greater probability of 
recovery from, chylous ascites than the male. In view, however, of the 
nature of the causative lesions-perforation or rupture of a chyle-convey- 
ing channel-the proportion of recoveries is remarkable. 
Bianchi says the prognosis is more grave when the extravasation is 
due to some chronic lesion of the chyliferous vessels than when it is due 18 
BUSEY, EFFUSION OF CHYLE. 
to a rupture of the thoracic duct, for the escape of lymph favors the 
union of the edges of the wound and the closure of the latter by thrombi. 
It is even more grave when the rupture of the vessel is due to abnormal 
distention caused by some obstacle because the process of healing is 
interfered with. The gravity of the prognosis is increased when there 
are concomitant visceral lesions. The immediate prognosis is perhaps 
more grave in chylous ascites than in the chylifonn. The more exten- 
sive the lesion of chyliferous vessels, and the larger the wounded or dis- 
eased vessel, the greater the facility of the reproduction of the ascites, 
and the more rapid and progressive the emaciation. 
There is no instance of the preservation of the life of an animal beyond 
a limited number of days, in which the communication of the lymphatic 
with the venous system had been completely and permanently oblit- 
erated. The wound inflicted by ligation of the thoracic duct could not 
have caused the death of the animal experimented upon, for in a number 
of cases it healed by the first intention ; neither could death be attributed 
to the rupture, either of the thoracic duct, lacteals, or receptaculum, nor 
to the extravasation of chyle or lymph into the pleural or peritoneal 
cavities, or into the cellular tissue about the abdominal viscera, for death 
took place in those cases in which neither of these conditions complicated 
the ligation of the duct, as it did in those in which one or more of these con- 
ditions supervened. When the animals, in cases of experimental ligation 
of the duct, recovered, the current of chyle and lymph was reestablished 
through anastomosis. Monro inflicted a wound in the receptaculum 
chyli of a pig, from which it apparently recovered, but effusion was 
arrested by a coagulum. Lower ruptured the thoracic duct of a dog; 
the animal died after languishing a few days, and two pounds of chyle 
were found in the right pleural cavity. Bartholini mentions a case in 
which the thoracic duct was wounded, and the patient lived a long time 
-" longa fuit tabes." Goodlad refers to the case of a man who was 
wounded in the duct, who seemed nearly cured, but finally died. 
The clinical and post-mortem cases, in which the communication 
between the venous and lymphatic systems was either partially obstructed 
or wholly obliterated, are not very numerous; and many of the reports 
are simple statements of bare facts, wanting in the particulars necessary 
to demonstrate the effect of obstructed conditions of the duct and lacteals 
upon the duration of life. Meagre and unsatisfactory as these clinical 
details are, they, nevertheless, point to two conclusions: 1st, that a free 
and unobstructed channel of communication between the venous system 
and chyle-conveying vessels is essential to the proper nutrition of the body 
and preservation of life; and 2d, that death following the partial or com- 
plete obliteration of this communication is the result of inanition. The 
gradual wasting of the body and progressive debility which so markedly 
characterize the clinical cases in which the flow of chyle, either through BUSEY, EFFUSION OF CHYLE. 
19 
the duct or anastomosing connections, was insufficient for the maintenance 
of the normal standard of nutrition, more decisively point to innutrition 
as the cause of death than the sudden exhaustion which follows the abrupt 
arrest of the flow of chyle and lymph toward the blood. In the experi- 
mental and traumatic cases there may be the superadded element of vio- 
lence, but this cannot be a potential influence, for it has been proven that 
in every instance of experimental obliteration of the communication in 
which death occurred, no anastomosing connection could be discovered, 
and in every case in which life was preserved, where proper methods were 
adopted to eliminate all doubt, such anastomosing connections were found. 
The causative condition must, undoubtedly, influence the duration of life, 
but without the loss of chyle it would, as, for instance, in cases of com- 
pression of the channel by a benign tumor, not be very significant. 
Clinical reports furnish many cases which illustrate the direct relation, 
as cause and effect, which subsists between copious losses of lymph and 
chyle and the marked depression, dulness, and exhaustion which invari- 
ably succeed abundant lymphorrhagise; and which, likewise, follow 
artificial occlusion of the thoracic duct, and so distinctly characterize the 
brief after-life of the animal thus permanently deprived of nutritive 
material. With but rare exceptions, the cases of copious loss of lymph 
have been attended with great exhaustion. The latter class may by rest, 
arrest of the lymphorrhagise, and proper alimentation recuperate, to suffer 
again and, perhaps, many recurrences, similar in course, duration, and 
effect; but copious and continuous loss of chyle is inevitably fatal. 
Cooper records the observation that young dogs experimented on by 
him lived longer than the old, and the lean much longer than the fat. 
In the clinical cases the average age of the fatal cases was thirty-one 
years, and in those who recovered it was twenty-four years, but the cases 
are too few, in which the ages are given, to attach any value, as an ele- 
ment of prognosis, to a difference of seven years. 
It is not possible to establish any constant and direct relation between 
the appetite and the obliteration, perforation, or rupture of the chyle- 
conveying channels. It lacks uniformity-sometimes diminished, some- 
times variable, and again voracious, even in the same patient, but is 
uniformly associated with progressive emaciation, quite often with fever 
of the hectic type, and gastro-intestinal disorder with white and chalky 
stools. In the case of chylous ascites reported by Poncy, from July 16, 
1699, to March 4, 1700, the date of his death, 289 French pints of fluid 
had been drawn in twenty-two tappings. The evacuated fluid was always 
chylous, and frequently emitted the odor of articles of diet. In this 
patient there were progressive emaciation and waste of all the tissues of 
the body. 20 
BUSEY, EFFUSION OF CHYLE. 
Nature of the Effused Fluid. 
In most of the cases of effusion into the pleural and peritoneal cavities 
the fluid was chyle, which had escaped from chyle-conveying channels. 
In the cases of lymphocele, it was altered lymph, consequent upon patho- 
logical processes affecting primarily the lymph vascular system. In the 
cases of milk-like, fatty, and oily fluid found in the peritoneal cavity the 
character of the fluid was the result of coexisting degenerative processes. 
Quincke, Friedreich, and Klebs have reported cases of adipose or fatty 
dropsy connected with peritoneal and mesenteric cancer. In some of the 
cases, especially so in the puerperal, the naked-eye observation of the 
milky appearance of the fluid was the only circumstance upon which its 
chylous nature was based. In several of the tubercular cases the analysis 
established its fatty and oily character, but did not prove it to be chyle. 
Bergeret's case of oily ascites was associated with suppurating glands ; in 
Hughes's case " cerebriform cancer " was present; and in one of Quincke's 
cases a cancerous nodule developed in the subcutaneous tissue at the point 
where the puncture was made to evacuate the fluid. In several of the 
cases abdominal tumors were found, but their nature was not determined. 
The fluid in lymphocele is lymph, in rare instances but slightly altered, 
containing more water and less corpuscular element, but usually, and 
especially in the parasitic variety, so changed as to be comparable to 
chyle. It varies in color from that of ordinary lymph to a canary- 
yellow, but most frequently is a milky, chylous, opalescent fluid, and 
always possessing the property of spontaneous coagulation. 
In either of the classes of effusion the fluid may contain blood, choles- 
terine, more or less of the common serous exudation, and some inflam- 
matory product. The chylous effusions are rich in solid matter, albumen, 
fatty matters, chloride of sodium, and sometimes contain bile, sugar, 
phosphoric acid, lime, and other undetermined substances, also pus and 
blood. They are either chyle with moderate admixture of extraneous 
elements, or chyle-like with more or less chyle dilution with peritoneal 
effusion and lymph. 
The appearance and chemical and microscopical composition of the 
fluid in chyle and chylous effusions are easily understood, but'why the 
fluid in lymphocele and other lymphorrhagise, or found contained, either 
in a fluid or partially coagulated condition, in lymph-cysts, sacs, or de- 
velopments, should so uniformly exhibit the appearances and physical 
and chemical properties of chyle, is not so susceptible of explanation. 
Numerous observations and analyses have been made of the fluids emitted 
in cases of lymphorrhoea and lymphorrhagia, and, with rare exceptions, 
it has been characterized as an opalescent, lacteous, or chylous fluid, 
rich in lymph-cells, albumin, and fatty matters, coagulating quickly and 
spontaneously. In all such cases lymph-stasis was the single condition 21 
BUSEY, EFFUSION OF CHYLE. 
uniformly present, and the alterations in the constitution of the lymph 
consisted chiefly in an increased proportion of fibrin, the addition of 
numerous cell elements, not unlike endothelial cells, white bloodcorpus- 
cles, occasionally red blood-corpuscles, lymphoid cells, granular matters, 
a varying quantity of albumen, and fat. 
Various theories have been suggested in explanation of this transfor- 
mation of lymph. The theory of chyle regurgitation is altogether unten- 
able. Buchanan maintains that the explanation of the white fibro-serous 
discharges must be sought "in the morbid activity of the multitude of 
epithelial cells, the function of which had become perverted," by which 
the fatty matter was eliminated from the blood. Petters offers the theory 
that the chyle-like fluids are due to fatty degeneration of the endothelium 
and other formed elements, and in the decomposition of protein sub- 
stances, which processes are brought about by lymph-stasis. Carter 
insists that the fluid was chyle flowing in a retrograde current from the 
lacteals through vessels defective in anatomical construction and directly 
connected with enlarged lymph glands. Fetzer suggested the absorption 
by the lymph vessels of the fat tissue of contiguous parts. Roberts held 
that the structures which produced these discharges " were anatomically 
related to the lacteal and lymphatic tissues, which, in consequence of 
hypertrophic development, had acquired " the property and functions of 
the cells lining the lacteal ducts and glands." Sedillot attributed the 
milky appearance of the fluid in Vidal's case to the presence of an infinite 
number of zodsperms, but their presence has been disproven; and Gos- 
selin expressed the belief that it was produced by a combination of the 
cholesterine and fatty constituents, but cholesterine has been but rarely 
found in such discharges. In view of the fact that the collections and 
discharges of such milk-like or chyle-like lymphous fluids are so gener- 
ally, if not always, associated with thrombosis, narrowing, dilatation, 
or occlusion of lymph channels, and lymph-stasis, the conclusion seems 
inevitable that they are pathological products. 
The fluid in cases of fatty and oily ascites, associated with cancerous 
or tubercular diseases of the peritoneum or other abdominal viscera, is 
not necessarily a product of such morbid conditions, for in such cases the 
disease may invade the lymph and chyle vessels, and cause rupture or 
perforation. Perforations were found in the cases reported by Whitla 
and Straus; in the former the peritoneum was studded with tubercles, 
and in the latter it was cancerous. In Guttman's case the oily fluid was 
apparently the product of a chronic idiopathic peritonitis. In all cases 
in which the thoracic duct, lacteals, or lymph vessels are diseased the 
presumption is in favor of perforation and escape of chyle and lymph into 
the cavity. In a few cases complicated with peritoneal or visceral tuber- 
culosis or carcinoma, the lymph and chyle vessels were normal. In such 
cases Debove maintains that fat is formed in the peritoneal cavity. 22 
BUSEY, EFFUSION OF CHYLE. 
Treatment of Chylous Ascites. 
In twenty-three of the fifty-three tabulated cases tapping was practised, 
and, in most of the cases, repeated several times. Six of these recovered. 
In two cases laparotomy was resorted to, with recovery of both patients. 
One was a case of an intact retention-cyst, and the other was, probably, a 
ruptured cyst. In the case of congenital cyst recovery took place after 
several tappings. In two of the cases of recovery, rupture of the umbili- 
cus occurred with spontaneous evacuation of the fluid. The frequent 
resort to paracentesis was manifestly due to mistaken diagnosis. As 
a medical resource its value is questionable. The peritoneum is an 
enormous absorbing surface, which, in cases of moderate effusion unac- 
companied with tension of the abdominal walls, might prove adequate 
for the reabsorption of the effused chyle and lymph. In cases of large 
accumulation, with its consecutive disturbances of the circulation and 
respiration, relief of the distention by the evacuation of fluid would be 
imperative, but it does not seem wise to empty the cavity completely 
of a nutritive fluid absorbable through such a vast area of lymphatic 
apparatus. 
The treatment has mainly been directed to the prolongation of life, 
and Murphy suggests that in " cases due to rupture of a chyle-duct it 
should be rest in bed, with light diet of such foods as are digested and 
absorbed by the stomach, . . . given in small quantities at short 
intervals, and a restricted quantity of water and other liquids, the object 
being to prevent distention of the ruptured ends of the lacteals and the 
formation of a coagulum." This, together with a general tonic plan of 
treatment, has, apparently, proven successful in at least two cases, and 
has certainly prolonged life in other cases. 
The causative condition may, in some cases, be amenable to medicinal 
treatment; but in most cases, especially in those in which the effusion is 
attributable to the pressure of a benign tumor, some surgical procedure 
might offer a prospect of cure. In case of chylous cyst (50) removal is 
certainly justifiable. 
In filarial cases the treatment applicable to such would be admissible. 
Guiteras asserts that patients " with filaria can hope for no permanent 
relief, except in the death of the adult worm. This happens occasion- 
ally, but cannot be brought about by treatment." Sonsino thinks some 
good may be accomplished in filarial diseases by the employment of 
astringents, such as gallic acid and the tincture of the chloride of iron, 
together with rest, tonics, and proper alimentation, but that alimenta- 
tion must not be pushed to the point of repletion and distention of the 
lymphatic vessels. 
Lancereaux asserts that filariosis, a term which he applies to the para- 
sitic forms of lymphatic diseases, is curable, though it may last for some BUSEY, EFFUSION OF CHYLE. 
23 
time. He has found mercurial inunction in the region of the affected 
glands of service, in connection with hydropathy, and suggests the injec- 
tion of parasiticides into the affected lymphatic ganglia to destroy the 
female adult worm. He, as do others, asserts that removal from the 
source of infection may result in spontaneous cure. THE AMERICAN JOURNAL 
OF THE MEDICAL SCIENCES. 
the first issue for 1890, The American Journal of the Medical 
Sciences enters upon its seventieth year, still the leader of American medical 
▼ | ▼ periodicals. In its long career it has developed to perfection the features of 
usefulness in its department of literature, and presents them in unrivalled 
attractiveness. It is the medium chosen by the leading minds of the profession on both 
sides of the Atlantic for the presentation of elaborate Original Articles; its Reviews are 
noted for discernment and absolute candor, and its Classified Summaries of Progress 
present, each month, an epitome of medical advances gleaned by specialists in the 
various departments. According to unquestionable authority, " It contains many original 
papers of the highest value; pearly all the real criticisms and reviews which we possess; 
and such carefully prepared summaries of the progress of medical science and notices 
of foreign works, that from this file alone, were all other publications of the press for the 
last fifty years destroyed, it would be possible to reproduce the great majority of the real 
contributions of the world to medical science during that period." Published monthly. 
$4.00 per annum. 
Tbc Medical Ne\Vs. 
With the beginning of the New Year the features of The Medical News as a 
newspaper will be largely developed. The province of a weekly medical periodical lies 
in furnishing its readers with prompt and condensed information relating to advances in 
all departments of medicine; and to this end, long and elaborate articles will not appear 
in The News. Only such material will be presented in The News as is thoroughly 
practical, and by judicious condensation ample space will be found to make every 
number one of interest and importance to every reader, whether general practitioner 
or specialist. Several new departments will be added, namely: Clinical Memoranda, 
Therapeutical Notes, Hospital Notes and Special Articles, giving opportunity for the 
presentation of much therapeutical and practical information in the briefest possible form. 
Necessarily different in their spheres, The American Journal of the Medical 
Sciences and The Medical News are mutually supplementary, and every reader of 
both periodicals may feel assured that nothing in the life of the great medical world will 
escape his attention. 
T/he year-]3ooX treatment for 188Q 
Gives a classified statement of the value and uses of all remedies which have been 
introduced and practically tested during the year. Price, $1.25 ; or in combination with 
either or both the above journals, 75 cents. 
Yhe JVIedical fie safe Visiting List for 18Q0 
Contains 48 pages of indispensable practical information and data and 176 blank pages, 
ruled to accommodate all records of practice. Handsomely bound in red seal, $1.25. 
In combination with either or both above periodicals, 75 cents. Thumb-letter Index, 
for quick use, 25 cents extra. 
LEA BROTHERS & CO., PUBLISHERS. PHILADELPHIA. 706 & 708 SANSOM STREET.