The indications of mediastinitis consist of intrathoracic soreness and pain, increased upon coughing and deep inspiration, difficulty of deglutition, disturbances of respiration and of heart action. Any irregularity of the pupils is evidence of irritation along the sympathetic nerves. Displacement of the heart means accumulation in its neighborhood and pressure disturbance. The lesion which will produce this will probably give dulness on percussion, and alterations of the ordinary chest sounds. With trouble high in the thorax the recurrent laryngeal may be involved, with the inevitable change in the voice. If the pneumogastric be compressed there will be rapid and irregular heart action. If the esophagus thus suffer dysphagia will result. Should the presence of pus be suspected a differential blood count may do much to clear up the diagnosis. Should pus come near the surface it will probably give the ordinary surface indications which one should be quick to appreciate and to relieve. Collections of pus within the chest tend always to migrate and pus may burrow to a considerable distance.
Treatment.
—The treatment of phlegmonous mediastinitis mainly depends upon recognition of the lesion and its degree of accessibility. Certain deep forms are hopeless, since they tend to kill before even pus can be located and evacuated. So soon as there be found any surface indication surgical attention should be promptly given. Any of these cases may be complicated by septic conditions within the lung or accumulations within the pleural cavity. The latter at least may be recognized and relieved. The proper use of the exploring needle may afford much information, and, in the presence of suitable indications, the sternum should be trephined and exploration made behind it. The main thing in all these cases is to distinguish between pressure effects produced by phlegmon and those due to aneurysm or tumor. Only rarely, and then only by surgeons of wide experience, should radical measures be attempted for the latter. Chronic processes, of tuberculous character and leading to formation of cold abscesses, will usually produce symptoms much less urgent, while the nature of the relief to be afforded will scarcely be left in doubt.
PLATE XLIX
Neurofibroma of Skin.
TUMORS OF THE THORAX.
Primary tumors of the chest wall constitute less than 1 per cent. of those occurring in general practice; this, of course, not having reference to secondary developments from cancer in the breast, which are somewhat frequent. Of the benign tumors those which most frequently appear upon the surface are the lipomas, which are seen either in circumscribed or diffuse form, as illustrated in [Figs. 507] and [508].
Fig. 507
