Physiological Laboratory, Surgeons' Hall.

Transcription

1 OBSERVATIONS ON THE COMPOSITION AND FLOW OF CHYLE FROM THE THORACIC DUCT IN MAN. BY D. NOEL PATON, M.D., F.R.C.P.E., Lecturer on Physiology, Edinburgh School of Medicine, Surgeons' Hall. Physiological Laboratory, Surgeons' Hall. So far only three systeinatic analyses of human chyle have been recorded. In 1842 Rees published' an account of the composition of the chyle taken from an individual after execution. The thoracic duct was opened one and a half hours after death and about six ounces of chyle were collected from it by gently knteading the abdomen. The subject had taken two ounces of bread and four ounces of meat on the previous evening and a small piece of toast about an hour before death. In his " Physiologische Chemie," 1877, pp. 596, 597, Hoppe Seyler gives the results of the analysis of the chylous contents of a pleuritic effusion apparently caused by a rupture of the thoracic duct. Hasebroek' describes the composition of a pericardiac effusion obtained after death which presented all the characters of chyle. It is impossible to say how far the composition of any fluid taken from one of the serous cavities may be modified by the absorption of certain of its constituents. The following table gives the results of these observations- I Philos. Trans Ztsch. f. die phyjsiol. Chernie Bd. xii., p

2 ~~~D. NOEL PA TONv. Rees Hoppe Seyler Hasebroek Water 904/ Solids '612 Organic Proteids Fats Cholesterin 9 V Lecithin P771 Soaps Alcoholic Extract Water Extract %555 Inorganic Soluble Insoluble 0'350 In the present instance the chyle was obtained directly from the thoracic duct, a fistula having( resulted from an operation uponi the root of the neck. L. S. aged 62, was admitted to Mr John Duncan's Wards in the Royal Infirmary of Edinburgh, with a large sarcoma in the posterior triangle of the neck. He was operated upon on August 5. The tumour was situated below the sterno-mastoid and ran beneath the clavicle, involving the carotid sheath. During the operation the internal jugular and subclavian veins and the termination of the thoracic duct were clamped with forceps. The patient did well, but on the forceps being removed ten days after a large flow of milky fluid occurred from the wound in the neck, and this continued up to the time of death. I am indebted to Dr Hodsdon who had charge of the patient during the autumn for the opportunity of making the following observations. I first saw the case on my return to town in September, only a few days before the fatal termination. At this time there was a constant stream of milky fluiid from a granulating wound above the left clavicle. Rate of Flow. It wa-s found impossible to collect the fluid by the insertion of a drainiage tube as any attempt to probe the wound at once produicedi baeinorrhage.

3 COMUPOSITION AND FLOW OF CHYLE. An attempt was made to estimnate the rate of flow by the application of large sponge dressings, but these failed to catch all the fluid. A caoutchouc bag carefully rendered aseptic was next applied in valious ways, but on account of the position of the wound it was found impossible to prevent a very considerable loss of fluid. After several days had been spent in these unsuccessful attempts, during which the patient became markedly weaker, the rate of flow was estimated by allowing the fluid to trickle into a small c.cm. measure and observing the amount discharged during short periods of from 3 to 8 minutes. It was impossible to make observations of longer duration as the patient became querulous and complained of faintness. By this timne the flow had greatly diminished, being only about one third as great as formerly. He died suddenly on the morning of the 11th Sept. A post-mortem examination was not allowed. Rate of Flow. ill Duration of obser- vation in minutes Amount of fluid in c.cm. Sept a.m p.m p.m. 8 5,, p.m Average 1 c.cm. in 1 min. or 1584 c.cm. in 24 hours. While the patient was in a more normal condition, the flow was at least twice, almost certainly three times, as great as this. Consequently it must have been between 3168 and c.cm. in 24 hours. The patient was too weak to be weighed, but his weight was about 60 kilos. Thus the flow must have been between 5 28 and 7-92 kilos per 100 kilos of body weight. Schmidt calculated that in the foal, the flow of lymph amounted to 6-13 kilos per 100 kilos of body weight. Analysis of F7uid. Four specimens were procured for analysis. No. I. was procured on the 5th by squeezinig which had been on all night. the sponge dressing

4 112 D. NOEL PA TON. No. II. was procured in a similar mnanner on the 8th from the sponge which had been on the wound during the day. No. III. was from the sponge dressing during the night of the 8th. No. IV. was collected in a c.cm. measure directly from the wounld on the 9th. The chyle invariably coagulated rapidly, and the analysis of 1. II. and III. is of chyle minus the fibrin which was left in the sponge. Specimen IV. was analysed entire. The method of analysis in I. and II. was the following: Abouit 10 grms. were placed in a weighed vessel anid weighed. It was then slowly dried over a water bath and in a hot air chamber at 1000 C. till no further loss of weight occuirred. Trhis gave the total solids. These were then strongly heated and the ash determined in the usual manner. Another portion-about 5 c.cm.--was diluted with water to about 20 c.cm., acetic acid was added, and it was then boiled for several minutes till a flocculent precipitate of the proteids, carrying with them much of the fats, had separated out. This was thrown on a dried weighed filter paper and the absence of albumin from the filtrate was determined by testing, with acetic acid and ferrocyani(le of potassiumn. In no case was there any precipitate, buit in all three the xanthoproteic reaction was present. The precipitate was washed with hot water, with.alcohol, and many times with ether to remove all the fats, and again with alcohol, driedl and weiglhed. This gave the proteids-serum albumin and serum globulin. A third portion was slowly evaporated to dryness, and the fats, cholesterin and lecithin extracted from the residue by Soxhle t's apparatus. The cholesterin and lecithin were determined after the method described by Hoppe Seylerl. In No. III. the etherial extract and proteids were determined by Hoppe Seyler's method as a check on the methods described above2. Of No. IV. only about 8 c.cm. were obtained, and the total solids, organic and inorganic, alone were determined. The diet on the 4th consisted of Milk 40 oz., Beef Tea 27 oz., Brandy 2 oz., one Egg and a small piece of Chicken. This diet contained approximately Proteids 20 grms. Fats 50 grms. Chemi.nsche Analyse, p. 425, 2 Ilbid., p. 423,

5 COMPOSITION AND FLOW OF CHYLE. On the 8th and 9th the diet was composed of Milk 70 oz., Beef Tea 40 oz., Brandy 4 oz., and 2 Eggs. Approximately the patient took each day Proteids 45 grms. Fats 85 grms. supposing beef tea to contain *8 0/0 Fat and *3O/0 Proteids. Composition of Chyle in Parts per thousand. I II III IV Sept. 4, 5. Sept. 8. Sept. 8, 9. Sept. 9. Water 943* Solids Inorganic Org,anic 49' Proteids Fats Ether extract 2406 Cholesterin lost 0o *Lecithin 036 * The Lecithin is calculated from the magnesium phosphate as directed by Hoppe Seyler (p. 426) by multiplying by As the magnesium phosphate weighed only grms. the possible error is considerable. The chief points of interest in this table are First, the small percentage of solids and their steady decrease during the course of the observation. Second, the tolerable uniformity in the amount of the inorganic substances. Third. the very small amount of proteids-only one-third of that found in Hoppe Seyler's case, and one-sixth of that in Rees's and Hasebroek's. This- is of interest when taken in connection with Senator's experiments on the influence of blood pressure on the composition of exudations1. During the present observations the patient's blood pressure was very low. Fourth, the correspondingly small amount of cholesterin is of interest as indicating that this substance has a source common with the proteids. 113 PH. XI. 1 Virchow's Arch., Bd. cxi. p

6 114 D. NOEL PA TON. The close correspondence in this respect of the present case with those previously recorded is shown in the following table. Relationship of Cholesterin to Proteids. Hoppe Seyler Hasebroek 1 21F7 Noel Paton 1 22 Although lhasebroek attempts to establish a relationship between the cholesterin and lecithin and the fats, no such relationship can be determined. Lecithin Cholesterin Fat Hoppe Seyler Hasebroek Noe1 Paton The relationship of lecithin, cholesterin and proteids in these three cases is as follows. Lecithin Cholesterin Proteids Hoppe Seyler Hasebroek I :19 41 Noe1 Paton Fifth, the large proportion of fats is probably to be accounted for by the comparative richness of the diet in these constituents.