canmedaj00659-0028

Canad. M . A . J. Aug. 1951, vol. 6 5 SCHAFFNER A N D KIRKPATRICK: CHYLOTHORAX CHYLOTHORAX V . D . Schaffner, M.D. a n d T . A . Kirkpatrick, M.D. Kentville, N.S. CHYLOTHORAX, from any cause, i s a rare condition. T h e most frequent i s traumatic, either b y direct wounding o r tearing o f a duct, fixed b y some disease, b y unusual move- ments of the spine. With t h e ever increasing surgical invasion o f structures adjacent t o t h e thoracic duct, i t s injury may become frequent a n d commonplace. I t, therefore, becomes justifiable t o report single cases o f a condition that in t h e past has resulted in at least a 5 0 % mortality rate. I n this paper no attempt will b e made t o review t h e literature. This h a s been amply done in a f e w recent articles, particialarly those o f Lampson a n d Baldridge e t al.,' Lampson,3 a n d Meade e t al.4 It should be mentioned, how- ever, that practically al l articles on t h e subject, a n d certainly a l l textbooks, that we have been able t o review, condemn an y attempt a t surgi- c a l correction. Th e vast majority o f authors state very definitely that n o t only i s surgery useless, b ut actually harmful, some going s o f a r a s t o state that i t results in 100% mortality. This, in view o f recent experience, o f course, h a s proved t o be incorrect. It should be mentioned i n passing that there i s n o "normal" anatomy o f t h e thoracic duct, there being marked variations in a t least 50%o o f cases. T h e general anatomy o f t h e duct, how- ever, i s well understood, an d i ts location a n d approach quite constant, particularly t h e lower end. T h e symptoms a n d signs a re those o f massive pleural effusion, producing a l l t h e mechanical effects o f such a condition, coupled with rapid nutritional deterioration d u e t o t h e loss o f t h e large amount o f nutriments, water, an d salts, *contained in t h e chylous fluid. Th e re-accumula- tion o f fluid i n h e chest after aspiration i s probably more rapid than i t i s from any other causes. T h e physical a n d chemical properties o f chyle ar e characteristic. It h a s a milky appear- ance an d a creamy layer separates o u t slowly on standing. T h e f a t globules a r e fine. As a rule i t h a s no but occasionally h a s t h e odour o f food recently eaten. Th e specific gravity generally exceeds 1.012. It resists putrefaction, thus explaining t he rarity o f i n- fection i n such cases. T h e f a t content i s high being from 0 . 4 t o 4.0% depending upon diet. The total protein generally exceeds 3 g m . per 1 0 0 c.c. Th e salt content i s approximately 0.8%. I t, therefore, becomes apparent that a large proportion o f essential food elements an d salts a r e carried to t h e blood stream via the thoracic duct, a n d t h e loss o f chyle consequent t o rupture o f t h e duct results i n rapid and pro- found nutritional deficiency. Chyle i s rich i n lymphocytes a n d one o f t h e signs o f i t s loss i s a decrease in the circulating lymphocytes. F o r some unknown reason i t i s also associated with a fall o r disappearance o f eosinophiles i n t h e blood. (This was not s o in ou r case probably d u e t o t h e particular type o f rupture). The treatment usually described i s mere pal- liation, consisting o f frequent aspirations a n d t h e attempted replacement o f essential food elements a n d salts i n t h e hope that t h e rupture o f t h e duct will spontaneously close. This, a s mentioned before, seldom occurs a n d death re - sults i n a high proportion o f cases. Since t h e chyle enters t h e blood streamn directly, i t appeared at first that t h e sugges- tion5 that aspirated chyle should be given intra- venously, was a good one. Infusion o f aspirated chyle h a s been used without mishap b y a num- ber o f authors, b u t others have reported sudden death from i t s use. It i s now n o t generally recommended. Other methods o f treatment ranging from special diets t o t h e yarious methods o f lung compression have suggested, none o f which have improved t h e over- a l l picture. T h e most hopeful conservative treatment i s that suggested b y Meade.4 This consists o f constant suction aspiration i n t h e hope that t h e pleural space will become obliterated b y adhe- sions a n d t h e rent i n t h e duct become closed i n th e process. He has successfully applied this niethod o f treatment. Th e most rational major surgical correction would appear t o b e that suggested b y Baldridge a n d Lewis,' Hodge a n d Hunter,2 Lampson,3 a n d Meade e t al.4 Briefly, this consists o f ligation o f t h e duct below t h e site o f rupture, usually just above t h e diaphragm. Th e cisterna chyli may be excised after ligating i t s collecting tubules. Th e approach i s through t h e right chest regard- less o f t h e side o f t h e effusion. This, o f course, 1 21

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