NORTH CAROLINA MEDICAL JOURNAL. A SEMI-MONTHLY JOURNAL OF MEDICINE AND BY JAMES B. BULLITT, M. D., Louisville, Ky. Stenographically Reported for this Journal. HAVE a contrivance which I would like to exhibit, for the purpose of producing local anesthesia, and so far as I know attention has not been called to it. It is by the use of carbonic acid gas. I have been familiar for sometime with the use of this gas in the manufacture of ice in the system known as the carbon anhydride system, a very excellent system for produing ice, and it occurred to me the gas could be used very well for local anesthesia. After several trials the instrument before you was decided upon for experimental purposes, and I may say, works very well. The storage drum contains twenty pounds of the gas which has been liquified by very high pressure; probably 1200 pounds pressure at room temperature would be necessary to convert this gaseous matter into liquid form, and when pressure is released expansion of the liquid returns it to the gaseous state. It seems that local anesthetics are becoming more and more used, and this may turn out to be of some service. It would be a very cheap method of producing local anesthesia. The drum which I have here cost $3.50, but could be bought for $3.00 with proper arrangements. When exhausted the drum can be *Reported to the Louisville Surgical Society. recharged. Attached to the outlet of the drum I have a small brass pipe at the end of which I have arranged a hypodermic needle, and by turning the small top valve the gas is liberated, and passing out through the small pipe through the hypodermic needle, you will see it produces a small cake of ice in the piece. of cloth held in my hand in a very few sends. The exact length of time I am not prepared to say, as I have not made an accurate test. When turned on the hand it immedately produces a white spot like ethyl chloride. It is apparently a very harmless procedure. Of course it would be impracticable to carry around a drum of this size, but I am sure that it would be a very simple matter to costruct a similar contrivance which would contain from one to two or three pounds which could be operated in the same way. The amount would have to be determined by experimentation. One thing in favor of the carbonic acid gas for local anesthesia is its comparative cheapness. Ethyl chloride is very effective but is rather expensive. STABWOUND OF THE THORACIC DUCT.— BY W. H. LYNE, M. D., Richmond, Va., Demonstrator of Surgery and Demonstrator of Normal Histology, Medical College of Virginia; Late Resident Physician D City Almshouse Hospital, Richmond. URING my service in the City Almshouse Hospital of this city, many were the unusual, interesting, and instructive cases that came under observation, since this is the only emergency hospital here. Often cases of such rare occurrence befell the lot of the ambulance surgeon as to be regarded as surgical curiosities, chief among which is the following, viz.: a stabwound of the thoracic duct at the base of the neck, the result of a midnight street brawl. *Read before the Richmond Academy of Medicine and Surgery, August 9, 1898. Dr. John A. Wyeth, in his most iucid essays on ligations, describes, on account of the proximity to the cervical blood vessels, the anatomy of the thoracic duct, which is but little larger than a goose-quill near its termination, as followɔ: "On a level with the insertion of the scaleuus it arches to the left, crosses in front of the subclavian, in front of the scalenus, behind the internal jugular and curves downward to empty into the subclavian at its junction with the jugular to form the left innominate vein." Posteriorly to the origin of the sterno-mastoid muscle, lies the small anatomic field bisected by the following vital structures--the pneumogastric and phrenic nerves, internal jugular and subclavian veins, subclavian and left common carotid arteries, the thoracic duct and the near by brachial plexus, a field which the mighty dare but enter after the most careful deliberation and thorough study, yet the would be assas sin's knife plunged amid this network of vital structures wounding only the thoracic duct. On account of the rarity of injury to the thoracic duct, many works on surgery absolutely ignore the subject while others dismiss it with a paragraph Very little is recognized in life concerning diseases of the thoracic duct, necroscopic findings, however, demonstrating their existence as seconda y chiefly to a tubercular condition or a suppuration in some of the nearby viscera or lymphatic glands. Pus, blood, bile, and even calcereous matter and concretions have been found in the duct; a rare case of ossification of the duct has been noted as well as one of gangrene. Sir Astley Cooper's experiments on animals revealed that gradual compression of the duct resulted in its dilation, whereas rupture resulted if suddenly compressed; during intestinal digestion, a compression of only a few minutes sufficing to ef fect a rupture, this being readily explained since the duct at this time is normally distended, due to the absorption of the digested fats, brought thither by the lymphatics, the sole conductors of this force-producing product. Where pressure is gradual and permanent, a chylous engorgement ensues, resulting in the establishment of a collateral lymphatic circulation. A varicosed thoracic duct, like a varicose vein is subject to rupture, discharging, according to locality, into or behind the peritoneum, into or behind the pleura, into the posterior medias tinum, or into the bladder; the effusions producing chylous ascites, chylothorax or chyluria, a case of the latter condition. existing intermittently for fifty years in a woman. Several interesting reports of abdominal and thoracic paracenteses have been made, in which the fluid microscopically proved to be chyle, the quantity being enormous. For instance, 289 pints in 22 tappings; in another, 15 gallons in 68 days; and a third in which 11.8 litres were found and withdrawn post mortem from the pleura. The causes of rupture of the duct are (1) traumatism or (2) obstruction, which is produced, as in other ducts, by causes from within, as infiltrating or thickening of its walls, stenosis from cicatricial contraction, thrombi, etc., or causes from without, as pressure from neoplasms, etc. A cause not common to the obstruction of other ducts, but analagous, is the blocking of the venous outlet, produced not only by thrombus but by cardiac dilation with its subsequent venous engorge ment, which necessarily interferes with the discharge of chyle. into the subclavian vein. A case is reported where a child with a congenital heart lesion subsequently developed and elephantiastic swelling of the right leg with a papular eruption from which exuded a chylous fluid, such eruptions being associated with or alternating in cases of chylous ascites and chyluria. The frequency of concurrent phlebitis and lymphangitis readily explains the old term "milk leg," now known as a result of phlebitis. The association of thoracic duct disease, ascertained post mortem, with other tubercular conditons leads me to attribute the malnutrition and emaciation in this dread malady largely to this non-recognized cause. Experimental wounds in animals have demonstrated the spontaneous cure of thoracic duct wounds, yet death from inanition is to be expected in the vast majority of cases. Spontaneous cure is affected by either or both of two ways:(1) by contraction of the unstriped muscular tissue, which is circular but scant near its termination, along with the auxiliary elastic tissue, which is longitudinal; (2) by spontaneous coagulation of chyle, a property acquired after having passed through the mesenteric glands. Not only are the functions and histologic structure of lymphatics and blood vessels nearly analagous but also the results of wounds of each, longitudinal ones bleeding less freely than transverse, the severed edges being more readily apposed. As in other ducts, longitudinal wounds in healing are les liable to be followed by stricture. Since the molecular basis of chyle is emulsified fat (this giving it its milky color, being colorless except during intestinal digestion), it becomes patent that a system deprived of this compound as well as its circulating medium, the excess of the albuminous liquor sanguinis must necessarily suffer; the patient gradually wasting away if the sequel be a stricture or dying from starvation if the duct be completely severed. The following case is of more than ordinary interest aside from its infrequency, since recovery, followed by no ill effects, resulted: Case:- About 1 a. m. May 5. 1896, I was called to an emergency case at one of the police stations. On entering, information was given by some officers that a negro man had been stabbed in the neck and that white blood, like milk, was coming from the wound." A thoracic duct injury was suspected by exclusion, but I silently agree with them that "I had never seen white blood before. The negro, aged 24, was of splendid physique, being a porter in a large hay and grain establishment. On examination, an oblique stabwound about one inch long, depth unknown, was found above and behind the left clavicie and parallel with the outer border of the sterno-cleido mastoid near its attachment, thus, from the anatomy of the parts, necessitating a longitudinal wound of the thoracic duct. There had been considerable hemorrhage, which had stopped, and an abundant milky fluid was steadily escaping from the wound. For quite a time I was at a loss as to treatment, but, acting on the advice once given by an older physician, "to look wise, say little and do something if necessary, I decided to tampon, which was repeatedly done after having cleansed the wound with a weak, hot, carbolized solution, the packing of iodoform gauze and compress becoming soaked with chyle. On removing the patient to the hospital, the wound was again redressed under scarcely better aseptic surroundings, using a dressing of like character as before. When this dressing was applied, chyle was still escaping in good quantity, though the patient had been slowly moved nearly three miles. On removing the dressing during the ward visit about seven hours thereafter, the escaping chyle and oozing had completely stopped, and the regulation dressing was reapplied with the approval of the su:geon in-chief, Dr. J. G. Trevilian. |