A system of practical medicine. By American authors. Vol. 3

by Unknown

⁴ Amer. Journ. Med. Sci., Apr., 1873.

Goodhart⁵ records a case of acute mediastinal abscess resulting apparently from injury produced by the sticking of a piece of meat in the oesophagus. A case illustrating the possibilities of direct injury to this region by a blow or fall has been recorded by Bennett. In a middle-aged lady, previously in good health, an abscess slowly formed and presented a prominence over the upper part of the sternum. Two months before the lady had fallen in going up stairs, and struck the sternum against the stone edge of the stairs. These examples have been selected because they seem to cover the possibilities of directly determining causes.

⁵ Path. Trans., London, vol. xxvii.

SYMPTOMS.—There are three separate groupings under which the symptoms may be classified: (a) The latent symptoms, which include chiefly manifestations of intra-thoracic irritation or pressure; (b) the fulminating phenomena; (c) the physical signs.

As a rule, mediastinal abscess is accompanied from first to last by deep-seated and gradually increasing pain and tenderness on pressure over the sternum; but it may be a sense of constriction and oppression with boring or throbbing sensations. Sometimes there is merely a sense of uneasiness about the chest, with pains of a rheumatic or neuralgic character in the shoulders or neck, brought about by irritation of the intercostal and humeral nerves. The general health may be impaired, and irritation of the pneumogastrics may be manifested by dyspepsia, nausea, vertigo, syncope, headache, dyspnoea, and inability to lie down. Laryngeal irritation is shown by cough, or spasm, with dryness of the throat; a frothy mucus may be expectorated, with occasional rigors, sweatings, and irregular febrile movement. When abscess follows severe injuries, such as fracture or wounds, distinct evidences of phlegmon appear, possibly within a week, accompanied by intermittent fever with rigors, and a sense of weight and oppression in the front of the chest, with pain in coughing and drinking, or breathlessness, "as if one had been running" (Petit).

The pressure symptoms of mediastinal abscess are never so grave as in other forms of mediastinal tumor, since the diffluent contents of an abscess occasion less compression of the mediastinal viscera, or when the intra-thoracic tension is excessive it seeks a channel by which the pus is evacuated. The pressure symptoms are least marked when the abscess is located in the anterior mediastinum.

There may be, on inspection, a distinct prominence over the upper part of the sternum, with or without redness or oedema. Palpation may enable one to recognize fluctuation on the borders of the sternum with tenderness. The tumor may pulsate, but the pulsation never acquires the expansile character of aneurism. Dulness on percussion may be marked, and, according to Daudé, the dulness under the sternum may undergo a change by alteration of the position of the patient. The heart sounds may be heard distantly and indistinctly. The respiratory murmur may be whistling over the region of the trachea, and in the chest a few moist râles may indicate venous congestion, with exudation into the bronchial passages; otherwise the condition of the lungs will probably be normal. The entire series of pressure symptoms common to intra-thoracic growths may be present, especially if the posterior mediastinum is invaded, and may correspond with those of mediastinal tumors in general.

DURATION AND PROGNOSIS.—The causal relations of abscess in the mediastinum are so various that it is only possible to decide the question of duration after weighing the possibilities of treatment. The persistence of the abscess is also decidedly governed by the thoroughness of the drainage after opening has been affected.

The PROGNOSIS depends upon the etiology and the fulfilment of the indications for treatment by drainage. Pressure on the heart and the great vessels which proceed from its base, the descending aorta, oesophagus, the pneumogastrics, and the internal thoracic circulation, must be considered as complications adverse to a favorable prognosis unless speedy relief is possible. Prominent pressure symptoms indicate an implication of the intra-thoracic glandular system.

COMPLICATIONS, TERMINATION.—The abscess may open into any of the internal viscera—the trachea, bronchi, or oesophagus. A favorable case terminating by rupture into the latter passage is reported by Bennett. At first a teaspoonful of bright fluid blood was coughed up, and the day following from two to three ounces of purulent matter followed. The discharge of pus continued five weeks, the sternal swelling subsiding pari passu.