MEDIASTINUM, DISORDERS OF THE.
Mediastinal Abscess.
Symptoms.—In an analysis of over one hundred cases I rare found that the inost constant and severe symptom of medi astinal abscess was pain, unless the formation was cold abscess, when the pain was a very unimportant factor. In both the acute and chronic form flashes of heat and rigors may oecur, particu larly the latter in the acute forms.
Pulsation may be perceptible by palpa tion and by the sensation of the patient from the pressure on large blood-vessels, and the sense of pulsation is intensified by the outside pressure upon the accu mulation. Abscess of the posterior spaces may, by its pressure on the nerves as they leave the cord, produce violent pain in the anterior wall of the chest. Dys phagia is not so marked as in other arowths of the chest. There is a sensa tion of weight under the sternum, the tissues overlying the latter being fre quently cedematous. Dyspncea is occa sionally complained of. General symp toms—fever, anorexia, etc.—are usually present, and become quite marked when the accumulation of pus is marked.
Case of abscess of posterior medias tinum, with cyanosis and subcutaneous emphysema; venesection; recovery by discharge through the lung.
A remarkable feature was a high de gree of subcutaneous emphysema, which extended over the neck and the upper part of the chest. -William Pepper (Triter. Med. Mag., Feb., '92).
Case of mediastinal abscess in a soldier upon whom a heavily-laden sack had fal len while he was lying down. Some days afteimard be experienced severe pain in respiration and gradually became weak and emaciated. Some eight months later Ile noticed a tumor the size of a hazel-nut on the right edge of the sterninn above the second rib. This grew rapidly, and in a month lie could only breathe when lying down, the sense of pressure being very great. An incision over the tinnor broug,11C12 3/, ounces of pus from above the sternum. The size of the incision was increased. Abundant irrign ion and cauterization with zinc chloride at 10 per cent. were then employed, with tampons of iodofonn gauze, but no sutures. Tte eovery WaS uneventful. ITa ssler ( Sem. 1\TM., Oct. 10, '94).
Diagnosis.—The pressure on the im portant nerves involved the pneumogas tric, the recurrent laryngeal, etc., and • A- I .1:1 z • It, r in 'Pie difficulty in sound of voice _ of thoracic it \ /1- 113111 :It times ex . .11 • I:, m is usually absent, irlsed discomfort.
d in suppuration of important, owing to rupture of an abscess .•.. 6 . r s cavities. terminating in ,• • :,s. per tonirs, pericarditis, or later Etiology.— le(liastinal abscesses. may - -I stcondary, or traumatic.
.L" idi( athic form is quite rare; the • : 1..rv f( IllaV result from lesions r.ng parts, — the neck or '.• — while the traumatic follows c( ntusions. penetrating, wounds,
4:w fracture of the overlying- bones.
- the mediastinum affects males r•- r. fr. qucntly than females. In Hare's . •11 prop rtion was as 58 is to 10. 'Ir.: anterior mediastinum is the most !loin m seat for its development (in the T.. -IT ,rticn of to 19 instances of the d's a,-e in all the other spaces). The pro n of acute to cold abscess was also ^.-..«1 I y IIare to be as -10 is to 31 in 111 s examined. Mediastinal abscess is ^ nrly as frequent as cancer: it occurred cases of the 5?0 grol-vtlis collected.
is more frequent than sarcoma, v-bich only DO occurred, of the last • rr I r mentioned.
11,1:1,-tnal abscess is occasionally a Pott's disease, especially if • tw lower cervical vertebrfe are in- .
tvi,?. It Llso occurs as a : .7. e.frr r tracheotomy or msophacrotomy.
. /iv,- frequent cause, however, seems - pericarditis.
Pathology.—Mediastinal abscesses are rded usually with obstruction, to a .er or less extent, of air- and blood channels from the pressure upon them, aud are recognized by dullness on per cussion over the region involved. An opening may exi.st, or bulging of the ribs with pulsation may occur, but such an accumulation in the mediastinal spaces may not reach the exterior sur face, owing to the sternum in front and the spinal column with the heavy mus cles behind, while abscess of the middle inediastinum must involve the lungs or the lateral spaces before coining into notice.
Treatment.—The only safe course in such cases is to trephine the sternum and to carefully explore the mediastinum, ascertaining with an exploratory needle whether pus is present. This is usually ascertained -,vithout trouble. The cavity should then be opened, „-,.,-ently washed out, and drained.
The advantage accruing from drain age in other parts is greater in medias tinal abscesses, and early incision, or re section of a rib or portion of the sternum, is not only indicated, but demanded. The urgent symptoms calling for this course may be mentioned:— 1. Dysphagia, or pressure upon the cesophagris.
2. I•lnlargement to the left of the sternum, and at times to the right.
3. Displacement of important organs, such as the heart or lungs..
4. Dullness and flatness of the region of the lungs.
5. Thorough drainage may be made also when the cause of trouble is a cyst or a serous collection; so that no special difference need be made.
G. Chills or hectic indicate pyTinia. and call for systemic as well as local treatment.
Mediastino-Cardiac Disorders and In juries.
The heart is intimately associated w-ith almost all of the contents of the whole mediastinum, but especially the large veins and arteries, which commence or terminate, as the case may be, within the pericardium.