MEDIASTINO-PERICARDITIS iS a fre quent complication of mediastinal flammation and usually terminates in serous effusion before it is fully recog nized. At times the serous effusion is absorbed, as is the case in pleural ef fusions of a serous nature. The afebrile type of pericarditis may be fatal, how ever, and no effusion exist. The most serious result is suppurative pericarditis. Treatnzent.—Aspiration and drainage are indicated in serous pericardial fusions. Incision and drainage should be performed for the relief of tive pericarditis. The site for either of these operations is that between the fourth and fifth ribs,—about one inch to the right or left of the sternum.
Pericardial effusions should be treated in the same manner as pleural effusions, paracentesis being insufficient to cure suppurative pericarditis. Incision and drainage are essential, and should be executed as soon as the diagnosis of pus in the pericardium is made. The diagno sis of the purulent character of the effu sion is determinable only by exploratory puncture. This should be done at the upper part of the left xiphoid fossa, close to the top of the angle between the seventh cartilage and the xiphoid car tilage. Pericardiotomy should then be done after resection of the fourth and fifth costal cartilages, raising a trap-door of tbese cartilages and using the tissues of the third interspace as a hinge. The mammary vessels and pleura are thus ex posed and pushed to the left. The prog nosis is good after pericardiotomy for pyopericardium. Of 26 collected cases there were 10 recoveries and 1G deaths. Of tbe fatal cases, 9 were septic, and all the others which died had complicating lesions,—pulmonary, cardiac, or renal. J. B. Roberts (Med. NC WS, May 8, '97). 1 INJURIES.—Wounds of the heart and pericardium may now be classed as other injuries of a similar. kind, since Rehn has successfully sutured penetrating wounds of the heart with catgut. Rehn recommends free opening in cases of hmmothorax, and in limmopericardium this is necessary to prevent the formation of bloody froth. (James P. Warbanes, Annals of Surgery, Nov., '98).
Among the rarer injuries to the contents of the mediastinum that may be mentioned is rupture of the heart, which has been demonstrated post-mor tem. It may be diagnosticated by the peculiar pallor, the sudden cessation of the rhythm and beat of the heart, to gether with the total irresponsive con dition of the circulation to all stimu lants.
in 560 autopsies five deaths were fonnd to be due to rupture of tbe heart. These cases are of forensic importance, as they show a comparative frequency of this condition in certain class of cases. The youngest patient in the group was sixty-two and the oldest eighty-one. In all the cases the arteries were said to be fibrous, and in 2 almost calcareous. The pulse before the rup ture varied from 72 to 120. In only 1 was irregularity noted. In 2 there was hypertrophy of the heart, in 2 it N S stated to be normal, and in 1 there was a systolic murmur. ln -1 eases the rup
ture was in the left ventricle and in I in the right auricle. The microscopical examination showed no changes in 2 eases; in 1 there was fatty degenera tion; in another marked brown atrophy with loss of the transverse striations; and granular degeneration, cell-frag mentation, and somewhat similar micro scopical findings in another case. R. L. Leak (Amer. Medieine, Sept. 6, 1902).
Mediastinal Vascular Disorders and Injuries.
DISEASES.—The diseases of the blood vessels of the mediastinum are those found in the vascular supply of other ..r.sir. int arteritis, i.1..
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.1 •• 1111-,11, f the trzolsvexse arch , 4.ft t at tut limit into the meth .o. pool along the muscles ..1 ..t t and lar nx, caus .o ‘111% marked lividity ', oi the face and neck and ' Ilkt.1 .1. (1. Attlee': (Edinburghur , June, lnunctions of mercurial t, iodine, belladonna, and cam ..r may he made externally, r; t inbat intlammation. Depic t n 11 calomel and soda, or by vene ,-..:, .r, has givin marked relief. WouNt)s.—The vascular trunks pass • t the inediastinum are so that a missile which penetrates the mav travirse it without wounding ' any imprtant vein or artery. The aorta ? na Lava, when wounded, obviously niit admit of time for any arrest of '1,e lixmorrhage. The most prudent urse to pursue in all penetrating v..unds is to hermetically seal the outer ivourd. after turning the patient upon atiLcted, so that all blood may t e allowid to escape. I'his course has ntly stood the test of experience in rr.i1;tary surgery, and Senn counsels it, pr.•fi rince to opening the wound and :atin: any bleedin7 vessels. In case • gruit amount of blood should collect n the mediastinum, it may be evacuated f". ,t..r:. rly by resection of a portion of tl mar the point of the greatest n. The rise of temperature no .: af.rr wounds of this character be m irP the absorption of fibrin a•••ual luemorrhap.e.
'In the sPnior editor's experience a •-•-e occurred in which a pistol-shot •rtf.erAed the mediastinum. the ball en ,i-ring immediately over the heart and 1 dgirg upon the sixth rib of the rig,ht • le tAind the axillary line. The ex tErnal wound was occluded, and the ball NN as not removed until after the general shoek and slight inflammatory reaction had passed off. The patient made a good recovery by the strict observance of mas terly inactivity.
This case — compared to another ill )11iielf the external wound WaS left open, terminating fatally — emphasizes the caution against cutting dam] and ex tracting a ball under such circumstances at the outset. The practice of removing balls lodged between the ribs is 11101T honored in the breach than in the ob servance. 'When an opening already has been made by the entrance of a ball, it is not good surg,ery to make another for the extraction, until the wall behind has become solidified. J. MCFADDEN GAS TON, Sn.]