Injury to the Thoracic Duct 
WITH AN UNIQUE AND INEVITABLE 
DEATH BY INANITION 
BY 
ALVIN EVER* M.D. 
CLEVELAND, O. 
Reprinted from the MEDICAL RECORD, August I, 1891 
NEW YORK 
TROW DIRECTORY, PRINTING AND BOOKBINDING CO. 
201-213 East Twelfth Street 
1891 Injury to the Thoracic Duct, With 
an Unique and Inevitable Death 
by Inanition. 
BY 
ALVIN EVER, M.D., 
CLEVELAND, O. 
Reprinted from the Medical Record, August i, 1891. 
December 17th last, Charles G. S was admitted into 
Lakeside Hospital with the following history: Rail- 
way brakeman, aged twenty-eight, with good general 
health up to the previous day, when he met with an ac- 
cident, the following report of which is as complete as 
could be obtained. By the slipping of a " push pole " (a 
pole attached by one end to an engine and used in mov- 
ing cars) he was so caught as to be squeezed against the 
foremost car and bodily rolled out from between the two. 
When picked up he was found several feet from the train 
and in an unconscious state. 
Upon being brought some thirty miles an examination 
brought to light little beyond severe localized pain in the 
right lower chest with some considerable injury to the 
right forearm, and a distinct band of discoloration some 
four inches in width, encircling nearly the entire abdo- 
men. While no crepitus was found it was still thought 2 
best to firmly strap the right chest as a precautionary 
measure against possible fracture of one or more ribs. 
This, with attention to the injured arm and such anodyne 
treatment as was required, was all that was deemed nec- 
essary for the time being. In the course of twenty-four 
hours, however, there was a rise of temperature and upon 
auscultation evidences of pneumonia, corresponding to 
point of injury over right lung, were plain. He was at 
once placed upon additional treatment, and for the next 
sixteen days seemed to run a favorable, yet perhaps se- 
vere, course of traumatic pneumonia involving the entire 
lung. 
Beyond somewhat more pain than one generally ob- 
serves in such cases, however, nothing unusual presented 
itself, except on the second day, when there appeared a 
gaseous distention of the abdomen and also enough dys- 
pnoea with a hyper-resonance of both lungs to suggest 
pneumothorax; but whether pneumothorax actually ex- 
isted or whether this condition depended upon the ab- 
dominal distention was not definitely determined at once 
and in twenty-four or thirty-six hours the whole chain of 
symptoms, in so far as the thorax was concerned, passed 
away, leaving the patient about as before with the excep- 
tion of more or less constant abdominal tympany. 
On the seventeenth day there came a great and most 
remarkable change over our case. Pain was complained 
of, and upon examination some redness with soreness 
upon pressure was found directly above and somewhat 
behind the anterior superior spinous process of the right 
ilium. Upon deep pressure fluctuation could be ob- 
tained ; and after the introduction of an exploring needle, 
an opening was carefully made quite down upon the ex- 
ternal oblique muscle. 
The moment the fistulous tract was struck there came 
a gush of most offensive gas, followed by a flow of nasty- 
smelling discharge, not unlike fecal matter both in ap- 
pearance and odor. So offensive was this discharge that 
the patient had to be removed from the general ward into 3 
an apartment by himself. An intestinal fistula was at 
once thought of, and in the next day or two, with the 
opening still discharging a fluid very similar in appear- 
ance to what was given him to eat (expressed beef-juice, 
milk, and whiskey), and with repeated assurances of the 
orderlies that its odor was identical with what had passed 
per rectum, the diagnosis of such a fistula confirmed itself 
in our minds without further or special investigation. 
After two or three more days the discharge lost its 
offensiveness to a very great degree; but otherwise re- 
mained much the same-opaque and milky-with marked 
increase of flow at any time the patient was asked to bear 
down as though at stool. At this time, too, rapid ema- 
ciation set in, and from these two facts-loss of odor 
and the unusually rapid emaciation-it was inferred 
that the intestinal lesion was high up and the food-stuffs 
given him came away as chyme. Under this belief it was 
deemed best to limit stomachic alimentation, as to quan- 
tity, and confine it entirely to predigested nitrogenous 
foods, while rectal feeding was pushed to its utmost limit 
Notwithstanding, however, this forced feeding and the 
apparent well-doing of his pneumonia the patient was 
still rapidly succumbing to starvation. So rapid was his 
inanition that it was estimated his body loss-from the 
date of fistulous formation (seventeenth day) to death 
(thirty-eighth day)-exceeded four pounds per diem, and 
that his entire loss much exceeded one half his normal 
body weight. 
During all this time we could see nothing to be done, 
more than sustain strength and life until such time as the 
patient's pneumonic condition would permit a restora- 
tion of the intestinal continuity, keep the tissues of the 
right side well open to favor drainage, and prevent 
sloughs. Starvation, however, went uninterruptedly on, 
and as already stated, death supervened on the thirty- 
eighth day after injury. 
This, then, briefly stated, covers the history, clinical 
course, diagnosis, and fatal ending of our case. To sum 4 
up its clinical significance we wiil take up : First, our 
diagnosis, not in its entirety, but only in so far as the fis- 
tula was concerned ; second, the autopsy and its findings; 
third, a study of the case, upon the whole, with the view 
of establishing a differentiation between fistulas com- 
municating with the thoracic duct, and such other 
fistulous tracts as may prove undefined or doubtful as to 
origin. 
i. In defence of our diagnosis of intestinal fistula I 
will only say : In the sixteen days' observation of the 
case there were, with but three exceptions, absolutely no 
indications of disease or injury other than those refer- 
rible to the right lung-now in an advanced stage of pneu- 
monia. 
With the appearance, therefore, of the painful bulging, 
followed by the rush of gas and fluid upon lancing, which 
plainly established the existence of some form of fistula, 
the exceptions-a band of discoloration, obstinate bowels, 
and slight tympany-were recalled ; and, for the life of 
me, nothing could have been plainer or more easy to 
diagnose. 
In fact, the whole case seemed too plain and simple to 
be mistaken. The gas and decidedly fecal smelling dis- 
charge in themselves moulded at once our belief, diag- 
nosis, and mistake. That there was a fistula was plain; 
that it was fecal was too plain, and there we rested. 
To give you the benefit that was given the House 
Staff, let me tell you, as was told them, how all this chain 
of occurrences happened : 
"You see this man was caught between the end of a 
pole and a box car; the little black and blue band about 
his waist plainly indicates to you what part of the body 
was caught. Now the pole must have so squeezed the 
abdominal parieties up against the car, as to impinge a 
knuckle of gut within its embrace; and while this did no 
immediate or serious injury to the belly or its contents, 
there still must have been enough harm done to subse- 
quently set up a low form of plastic inflammation where- 5 
by the gut and peritoneum became agglutinated and ad- 
herent one to the other. 
" In due time, of course, death took place in that por- 
tion of the gut and the delicate serous membrane which 
was most centrally located in the adhesion, and then the 
tissues gave way and the fistula became established. Of 
course it could not communicate with the abdominal cav- 
ity, because you see the opening through the gut and 
peritoneum was simultaneous; and as the healthy por- 
tions of the two are still adherent there is a sort of artifi- 
cial anus formed, and through it, of course, the fecal 
matter must pass, then force its way on through the 
extra-peritoneal tissues in whatever direction it finds 
least resistance. Observe as you make pressure on this 
side a wave appears on the opposite side, not far under- 
neath the skin, and beginning evidently in the linea alba. 
That is the fluid coursing its way through the newly 
made channel toward its outlet. 
" As to what can be done in such cases, for the pres- 
ent we will only make a freer opening, so as to give free 
vent and prevent the burrowing of fluids and subsequent 
sloughing. Later on, of course, when his pneumonia has 
subsided, laparotomy with, perhaps, enterectomy, will be 
performed, all of which will be a simple matter. 
" Stimulate and feed him well, for, as you see from 
what has been said concerning the character of the dis- 
charge, which really seems to be nothing more than par- 
tially digested milk, whiskey, and beef-juice, the lesion 
must be high up, and therefore the area for absorption is 
greatly cut off. 
" The discharge which, you will remember, was so very 
offensive no longer smells badly, which also means that 
the foods leave the canal high up, and therefore have no 
chance for decomposition. 
" This without doubt would be a nice case for Senn's 
hydrogen gas test, but, as the case is so plain and the 
poor fellow has already been badly hurt, we will pass that 
by. The pneumonia, of course, is a contra-indication for 6 
the use of an anaesthetic, so all we have done, as you 
know, had to be done under the local spray and cocaine, 
neither of which is very effectual." 
These, in substance, were the clinical points upon 
which was based our diagnosis two days after the fistulous 
formation. From then on the patient's pneumonia did 
well and seemed promising; and so was also our forced 
feeding borne well by him, but he starved to death on the 
thirty-eighth day, and thus ended our first lesson. 
Autopsy.-In making the autopsy it was at first deter- 
mined to follow the tract from without in, but as it 
proved to run an unfavorable course for such a step, the 
attempt was abandoned and the abdomen gone into 
through the linea alba-the incision extending from the 
ensiform cartilage to the.pubes. At first glance there 
could be seen many evidences of starvation's fearful rav- 
ages. All the viscera presented an unusual dryness, with 
the surface of the intestines and liver much darker in ap- 
pearance than normal. The gall-bladder was greatly dis- 
tended and seemed on the point of bursting; while the 
omentum, always so rich in fat, was but a mere network 
of blood-vessels and connective tissue. These points 
being noted the point of " adhesion " was at once looked 
for, but no such condition could be found; and then a 
search for the fistula began. For this we looked high and 
low. Applying a double ligature just above the sigmoid 
flexure and dividing the gut between the two, we emptied 
the abdomen from below up, carefully noting every patho- 
logical change as we went. 
Up to the diaphragm we failed to find even evidences 
of inflammation, new or old. In fact, the abdominal 
cavity seemed absolutely free from pathological condi- 
tions, and after going over the intestinal tract again and 
again, we thought it possible that the oesophagus might be 
the seat of lesion. So accordingly the liver and pancreas 
were removed and the diaphragm, beginning at the oeso- 
phageal opening, slit up to the ensiform cartilage. 
In removing the liver from its lodgment it was observed 7 
that it was adherent to, and much softened about the aortic 
opening in the diaphragm, with evidences of recent in- 
flammation, and several masses of a cheesy deposit, not 
unlike the residue of partially digested milkin appearance, 
embedded in its upper surface. The diaphragm up to 
the oesophageal opening also showed the same evidences 
of inflammation, and at this latter point the bands of 
muscle forming the opening were so adherent and matted 
to the gullet that, in separating and lifting the latter out 
through the cut made in the diaphragm, it was so torn as to 
prevent us from determining whether its destruction had 
been ante-mortem or made by us. From the character, 
however, of the blackened and broken-down tissues, not 
only of the liver blit the diaphragm and oesophagus, and our 
failure to find any other lesion, we momentarily concluded 
we had reached the seat of trouble. 
The sternum and cartilages were next removed and after 
carefully examining the diseased right lung, which was 
found in various stages of hepatization, the same was 
lifted out of the thorax, and the upper surface of the 
diaphragm about its openings further examined. Its con- 
dition was similar to that found below, except, perhaps, 
that the inflammatory process had not been so extensive. 
The gullet above this point was also further examined but 
found to be perfectly healthy. Upon complete removal 
of the lung from the chest there was discovered a bulging 
into the cavity, from the back and uppermost point of its 
apex, which upon more careful investigation was found 
to be a post-pleural collection of fluid. Upon tapping 
its sac this fluid seemed to be identical with that which 
had been making its escape per fistula during life, and 
further examination proved this finding to be correct. 
The pent-up fluid was our supposed chyme, and had bur- 
rowed its way between the pleura costalis and chest-wall 
by gravity while the patient was flat upon his back. A 
careful dissection also proved the incorrectness of our just- 
formed belief that the lesion could have been in the oesoph- 
agus at the point of opening in the diaphragm, for in 8 
no way could that tear and the newly found cavity be 
made to connect. This discovery, then, put us entirely 
at sea, and it was not until the bulging pleura was again 
referred to and its contents found to consist of a rich 
creamy clot, overrun by a brownish liquid, that a chyle- 
clot and lymph were thought of. 
Specimens were at once examined by heat and the 
microscope. The former clearly proved the fluid to be 
pure lymph, while the microscope showed us a collection 
of the most beautiful specimens of chyle-corpuscles ever 
looked upon. Thereupon the autopsy was brought to a 
speedy end by going directly into the posterior medias- 
tinum, and but little deeper than we had gone for the 
gullet, where the hard-looked-for hole was found-not in 
the alimentary canal, however, but in the thoracic duct. 
It was through this hole, then, that all our endeavors for 
the poor fellow's life had slipped. The fistula was found 
within the very opening formed by the diaphragm for the 
tube's reception, and the diaphragmatic crura, fasciculi, 
and interdigitations surrounding it likely had much to do 
with its formation, and probably led to the division of the 
stream of chyle, directing the one into the thorax and the 
other through the muscles of the back and abdomen to 
its ultimate point of outlet. 
Points of Differentiation, as presented in this case, bear- 
ing directly upon the non-existence of intestinal fistula, 
and somewhat plainly indicating division of the thoracic 
duct.-Under this head comes, first in order, Senn's 
hydrogen gas test. Had this test been applied, without 
doubt its results would have led to such further investi- 
gation as would have ultimately led to a correct diagnosis. 
Second, heat test and miscroscopic examination of fluids 
discharged. Had the former test been resorted to, these 
would surely have followed and a correct diagnosis might 
possibly have been arrived at. Third, shortness of inani- 
tion period. This, it would appear, should prove, in an 
otherwise healthy subject, a strong and emphatic diagnostic 
point indicative of thoracic duct destruction. 9 
The adult subject, it is well-known, succumbs to starva- 
tion in twenty to twenty-four days ; but the phenomenon 
generally takes place under the withdrawal of all nourish- 
ment. Here, while the subject was suffering from pneu- 
monia, and was supposed to have an opening near the 
stomach through which his food escaped, death still came 
entirely too soon ; for under the forced rectal alimenta- 
tion, life should have been maintained for many weeks 
longer, had the fistula been elsewhere than in the tho- 
racic duct. 
Comments Worthy of Record.-In endeavoring to 
arrive at the probable cause and time of lesion, which it 
seems to me would be of interest to know, two questions 
put themselves : Was it the destructive outcome of ex- 
isting inflammation and formed on, or about, the seven- 
teenth day ? or, Was it purely traumatic and formed on 
the day of original injury ? The inflammation about the 
aortic opening in the diaphragm and adjoining structures, 
as found in the post-mortem examination, with the inter- 
vening sixteen days before the fluid came to the surface, 
combined with the terrifically rapid emaciation after the 
seventeenth day, would all speak strongly in favor of the 
first proposition. 
In my judgment, as formed from a careful noting of 
the entire case, however, it would be under the latter prop- 
osition that the actual cause and time should be placed. 
In support of this, I would argue that the division was 
sustained in the accident, but happened to be so located 
within the grasp of the tendinous arch, thrown from one 
crus of the diaphragm to the other, that immediate, con- 
tinuous escape of lymph was checked, and the chyle-clot 
(found upon the removal of the liver) allowed to form in 
the tissues about the lesion, and so pack and arrange itself 
there as to temporarily dam up the break. . I believe this 
condition to have existed up to about the sixteenth day, 
when the inflamed tissues gave way and the burrowing of 
chyle began. 
The main point in support of this theory is to be found 10 
in the peculiar tympany appearing on the second day 
after the injury. The distention, which was not only 
peculiar in its mode of coming but remarkably so in its 
stay, could not, at the time, be accounted for. The 
symptom proved unusually distressing, because of the 
existing pneumonia, and in our efforts to dispose of it 
full doses of salts were given, but to no avail. While the 
bowel discharges were copious and watery, the tympany 
still remained. This, it now seems, must have depended 
upon the gas being in the peritoneal cavity, and not in 
the intestines; and from its existence and its time of ex- 
istence I infer it to have been a phenomenon coincident 
to the injury to the duct and also, therefore, a data fixing 
the time of said injury. 
As to the cause of such an injury one could hardly 
conceive its possibility. Whether compression of the 
lower abdomen could so forcibly crowd its viscera 
against the diaphragm and upon the, perhaps, well-filled, 
duct, as to injure it; or whether the squeeze to the chest 
could have caused such forced respiratory efforts as to 
produce it; or whether an over-excited diaphragm could 
cause it by its muscular contractions, are only possibilities 
to be conjectured, but not shown. How this tube, lying 
as it does between the aorta and vena cava, could be 
singled out and divided by causes either indirect and in- 
flammatory, or direct and traumatic, without also tapping 
one or the other of its fellow companions, seems to us as 
incomprehensible, in the study of nature's method of ap- 
plying her causes in obtaining her effects, as does it seem 
irrational that she should assign to this poor mortal a 
death so sure, yet indirect and terrible, as starvation, when 
she might as well have decreed the tapping of either one 
of said vessels and let forth his simple life in a single 
moment, without bodily pain or mental suffering. 
It will be observed that in the autopsy no evidences of 
inflammation were to be found other than those in the 
lung, diaphragm, and the structures immediately adjacent 
to its aortic opening. These, of course, must be regarded 11 
as entirely traumatic. The post-pleural cavity, contain- 
ing at least two pounds of chyle, with the channel lead- 
ing to it from the point of rupture in the duct, and also 
the upper two thirds of the tract through the extra-peri- 
toneal tissues, were as free from inflammation as though 
nature had formed and lined them. This latter condition, 
which positively demonstrates the non-irritability and 
homogeneousness of chyle to the textural structures of 
the human body, suggests two points of interest. 
1. Could the chemico-physiologist ever be enabled to 
elaborate out of food-stuffs a product identical with that 
made in the human digestive laboratory then it would 
appear the surgeon's skill and ingenuity might lead to 
some form of venous feeding whereby life might be in- 
definitely maintained. 
2. Bearing upon the much-discussed question of asepsis 
versus antisepsis the case in point furnishes much practi- 
cal information favorable to the former theory. Here 
existed a collection of chyle, pent up between delicate 
and sensitive tissues for a period of at least sixteen days, 
without the slightest evidence of inflammatory irritation. 
Had it been bile, gastric or pancreatic fluid, or even 
blood, surely no such inaction could have been expected. 
Upon what, then, could this difference depend other 
than the possession by the four latter fluids of materials 
septic to the body tissues, on the one hand, and the 
asepsis of the sterilized chyle, by virtue of its digestion, 
on the other ? The mechanical irritation, by contact, of 
this fluid must certainly be as great as that of sterilized 
water by boiling at blood heat; and therefore it would 
appear that the aseptic condition of the surgeon and his 
materials infuse should become in the end practical, and 
by all means preferable to the dangerously potent anti- 
septic remedies used as germicides. 
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