152 J. M. HAMILL. 



fairly good health and applied for treatment only on account of the 

 inconvenience which the condition occasioned. 



His lungs and heart were normal, and no enlarged lymphatic glands 

 could anywhere be detected. Over the lower part of the abdomen below 

 the umbilicus and to some extent over the right buttock was a soft 

 cedematous swelling. The right thigh and leg were also involved but 

 here the oedema was much firmer in character than in the abdominal 

 region. The scrotum was but little affected. The skin in the region of 

 the right groin was covered with a large number of vesicles varying in 

 size from a pea to a walnut. On the summit of one of these vesicles 

 situated in the region of the saphenous opening was a small hole from 

 which chyle issued. 



The abnormality was first noticed as a swelling in the groin when 

 the patient was ten years old. Four years later it became septic and 

 was diagnosed as a psoas abscess. An operation was performed and 

 a large amount of watery fluid escaped, the wound closing up for the 

 time being. Eventually, however, it re-opened and allowed of the inter- 

 mittent escape of a thin watery fluid. Septic trouble supervened from 

 time to time, the swelling gradually extending, the fluid discharge 

 becoming milky and increasing in quantity until the condition already 

 described was attained. 



The lymphatic fistula with its accompanying oedema is probably due 

 to congenital obstruction of the thoracic duct. 



The Chyle flow. From the open mouth of the fistulous opening in 

 the upper part of the thigh made by the patient himself and main- 

 tained by him as a means of relief a milky fluid constantly trickled 

 away. The flow could easily be checked by a firmly adjusted bandage 

 but as the fluid, which was constantly being formed, accumulated in 

 the subcutaneous lacunae the tension increased to such an extent as to 

 become insupportable and had to be relieved by allowing some of the 

 chyle to escape. At these times, when the controlling power of the 

 bandage was removed the pent-up chyle spurted forth in a jet of consider- 

 able force. In this way comfort could be obtained if about 100 c.c. of 

 fluid were drawn off each day. As we shall see later on, the daily 

 production of chyle is enormously greater than this; it follows, therefore, 

 that the blocking of the duct is by no means complete and that when 

 the pad and bandage are in position the greater part of the chyle 

 is absorbed, probably through dilated collateral channels, its passage 

 being aided by the increase of pressure consequent upon the continual 

 accumulation of chyle behind the obstruction. 



