A CASE OF MEDIASTINO-PERICARDITIS IN A 
CHILD; SECONDARY EMPYEMA; OPERA- 
TION; DEATH. 
BY 
WILLIAM A. EDWARDS, M.D., 
San Diego, California, 
Fellow of the College of Physicians of Philadelphia, American Pediatric and Philadelphia Patho- 
logical Societies; formerly Instructor in Clinical Medicine and Physician to the Medical 
Dispensary in the University of Pennsylvania; Physician to St. Joseph’s Hos- 
pital ; Associate Pathologist to the Philadelphia Hospital, and Mem- 
ber Advisory Council for the Section on Diseases of Chil- 
dren of the Pan-American Medical Congress. 
Reprinted from the International Medical Magazine for June, 1893. A CASE OF MEDIASTINO-PERICARDITIS IN A CHILD; 
SECONDARY EMPYEMA; OPERATION; DEATH. 
The early clinical symptoms of mediastinitis are most indefinite, and the 
disease is one that may be readily overlooked until some of the secondary 
or concomitant symptoms assist in clearing up the diagnosis; even then, 
however, the primary pathological change may escape detection unless a 
post-mortem is obtained. 
It is on this account that I deem the following case worthy of record : 
M. D., aged six, was under the care of Dr. Bowditch Morton, of Coro- 
nado, by whom I was called in consultation. The child was somewhat 
below the average in development, strength, and vitality; she complained 
of a constant pain, with marked exacerbations over the left costo-sternal 
region, extending from about the mid-sternal line to a little below the costo- 
xiphoid angle; over this region it was thought that there was some impair- 
ment of the normal percussion resonance, although this alteration was not 
marked. 
The cervical veins were distended, the action of the general circulation 
was tumultuous and irregular, the temperature was a degree and a half 
above the normal. The child remained in about this condition for the next 
thirty days, the temperature, however, remaining high, sometimes 103°, 
usually 101°, rarely normal, if so, remaining at that point for a few hours 
only. Upon the next consultation, dulness was marked in the region above 
described, and extending towards the left anterior axillary line. 
The respiration and circulation were much interfered with, the former 
was recorded at from 28 to 40 per minute and the latter from 135 to 160. 
No pericardial or exocardial murmur could be detected now, or at any 
future time during the progress of the case; slight oedema of the face was 
present and a similar condition about the ankles. The liver was somewhat 
enlarged, but ascites did not arise. 
The temperature was now ranging from 103° to 104.5° in the afternoon 
falling to 99.5° or 100° in the morning. No sweats. Urine contained 
albumin. 
An aspirating needle was introduced at a point a quarter of an inch 2 
WILLIAM A. EDWARDS, M.D., OX 
within and above the position of the normal apex-beat of the heart; pus 
was obtained. Ether administered and incision made, nine ounces of pus 
removed, and a rubber drain inserted ; dressed with iodoform gauze and 
bichloride cotton. 
The child was much relieved. 
Within a fortnight I was again called to the case, Dr. Morton’s record 
showing that the temperature was far above the normal,—maximum 105° 
F.,—the case was not progressing favorably, notwithstanding the fact 
that the drainage was good and sufficient. Careful physical examination 
demonstrated a collection of fluid, probably pus, within the pleura, evidently 
sacculated; an incision was made in the eighth interspace, at the post-axillary 
line, the point of maximum dulness, sixteen ounces of pus was removed, 
and a rubber tube inserted as before. 
The child again did well for a few days, large masses of fibrin came 
away in strings and sheets; the drainage was good, but the temperature 
remained high (102° to 104° F.); tonics, nourishing food, stimulation, and 
out-door life were resorted to, and the little patient gained somewhat. The 
empyematous cavity, however, did not decrease much, if at all; the discharge 
decreased, the rubber drains were shortened daily, and finally it was decided 
to resect the ribs, which I did on January 30 of the present year, assisted 
by Dr. Morton. 
The vertical incision was used, with sliding of the integuments to either 
side to secure roo.m for the resection; a portion of three ribs was removed 
in a triangular manner with the base down. 
The child bore the operation well, reacted nicely, but died within a week 
from the prolonged drain and exhaustion incident to so much suffering and 
suppuration. 
An autopsy wras held, assisted by Dr. Morton, and an extremely inter- 
esting specimen secured. 
NOTES OF AUTOPSY ON BODY OF M. D. SIX HOURS AFTER DEATH. 
Panniculus adiposus almost absent. 
Thorax.—Right pleura, both visceral and reflected, is everywhere covered 
with recent lymph, which is also intralobular. The mediastinal space was 
practically obliterated through new-formed connective tissue, embedded in 
which was the heart with the pericardial sac adherent in places. In the 
region of the left ventricle was seen the (pericardial) sac which was the site 
of the first operation, here the pericardium was much thickened and covered 
by a pyogenic membrane. (See figure.) 
The left lobe of the liver was adherent to the diaphragm and the 
diaphragm in turn adherent to the pericardium ; indeed, the stomach, spleen, 
pancreas, and left lobe of the liver were matted together, the centre of the 
mass containing the spleen, which was situated in a deep sac. 
The kidneys were in a condition of chronic parenchymatous inflamma- 
tion. A CASE OF MEDIASTINO-PERICARDITIS IN A CHILD. 
3 
In the light of the post-mortem knowledge it appears, then, that this 
case was a primary mediastino-pericarditis, which within two months was 
followed by a purulent pleurisy. 
1, Anterior mediastinal tissues greatly thickened; 2, left lobe of liver, 3, stomach, 4, spleen 
(adherent to fragments of the diaphragm and all bound together in one mass); 5, the heart, with 
its cavities laid open, in situ; 6, pyo-pericardium; 7, left lung; 8, empyematous cavities, with 
sacculated pus cavities at 9,10, and 11; 12, thickened pericardium. 
The etiology of the case is obscure; no history of injury, exposure to 
cold, eruptive fevers, which Hare1 states is an etiological factor, or, in fact, 
any of the so-called predisposing or exciting causes of the condition under 
consideration could be obtained. The tubercle bacillus was not found at 
any time. 
It would seem, then, that the little child presented a primary inflamma- 
1 Mediastinal Disease, Fothergillian Essay, 1888. 4 
WILLIAM A. EDWARDS, M.D., ON 
tion of the entire anterior mediastinum, which of course included the 
pericardium; that my first operation was a paracentesis pericardii, followed 
by incision into the sac and drainage; the empyema was a concomitant 
through continuity and contiguity of tissue. 
The literature does not present a great number of similar cases, the very 
able article by Rotch in Keating’s “ Cyclopaedia” does not mention this 
association of disease. Ashby and Wright’s “ Diseases of Children” devotes 
some space to the symptoms and treatment of mediastinal abscess and medi- 
astinal pericarditis. 
The two cases of Ashby in the Medical Chronicle, 1891, vol. xv. No. 3, 
are typical and are very similar to the above, except that they do not appear 
to have been complicated by empyema, but pneumonia was present in both 
lungs. The post-mortem appearance in one of the cases, as regards the 
structures in and about the mediastinum, was almost identical with that of 
our case, tuberculosis was present, however. His second case had suffered 
from a past pleuro-pericarditis, accompanied by inflammatory mischief in 
the mediastinum, still earlier than this the child had suffered from an endo- 
carditis of the mitral valve leading to thickening and adhesion; the child 
succumbed to a general miliary tuberculosis, and the post-mortem demon- 
strated the conditions as stated. 
In my article in Keating’s “ Cyclopaedia,” on “ Affections of the Medi- 
astinum,” vol. ii. p. 729, two cases of simple or non-suppurative mediastinitis 
are presented, both males, and of the same age,—ten years. One of these 
cases was associated with pericarditis and the other appears to have been 
part of a general process involving the glandular structures of the medi- 
astinum. Both cases were fatal. 
Harris (British Medical Journal, 1891, ii. 1263) exhibited specimens of 
chronic mediastino-pericarditis from a boy aged fourteen, to the Manchester 
Medical Society. Boy had been ill eighteen months, suffered from dyspnoea, 
cyanosis, distention of neck veins, but no inspiratory distention of these 
vessels. A marked pulsus paradoxus was present, each inspiration producing 
a decided diminution in the volume of the pulse. 
Both pleurse contained fluid, more marked on left side. Liver enlarged. 
The pleurte were repeatedly aspirated, ascites, anasarca, and catarrhal pneu- 
monia arose, and child died within the week. 
The mediastinum contained a large mass that microscopic examina- 
tion proved to be inspissated pus. The pericardium was everywhere ad- 
herent. Liver showed marked venous congestion without any periportal 
cirrhosis. 
Eustace Smith’s (Medical Times and Gazette, ii., 1884) case of purulent 
pericarditis and empyema was aged two years and five months; autopsy 
showed double empyema and pyo-pericardium, the sac containing half a 
pint of pus; no observation was apparently made of the state of the medi- 
astinum. 
Hutton exhibited before the Manchester Medical Society (British Medi- A CASE OF MEDIASTINO-PERICARDITIS IN A CHILD. 
5 
cal Journal, London, 1884, p. 462) sections of the lung and liver of a boy, 
aged nine, who died of disease of the liver of fifteen months’ standing, con- 
sequent on mediastino-pericarditis. The lung showed general increase of 
fibrous tissue, thickening of the walls of the bronchi, and great enlargement 
and pigmentation of the lymphatic glands. The liver showed great increase 
of fibrous tissue around the portal vessels with multiplication of the bile- 
ducts, and slight cirrhosis of the hepatic vessels. The intervening capillaries 
were so much dilated as to give the section the appearance of a blood- 
containing sponge. 
Hudson (Dublin Journal of the Medical Sciences, vol. viii., 1849) has 
recorded an instructive case of a boy, aged twelve, in whom a friction sound, 
produced by emphysema of the anterior mediastinum, simulated pericarditis 
very closely both in its physical signs and clinical symptoms. 
The abstracts of some of the medical and surgical cases treated at the 
General Hospital for Sick Children, Pendlebury, Manchester, England, 
contain several cases worthy of note in this connection ; several of the cases 
demonstrate the connection between mediastinitis and hepatic congestion and 
enlargement. 
The Medical Press and Circular, London, 1884, N. S. xxxvii. 45, con- 
tains a case of mediastinitis in a boy aged seventeen, following trauma; 
other cases are noted in British Medical Journal, 1884, i. 63, boy aged 
eighteen; Boston Medical and Surgical Journal, 1867, lxxvi., boy aged 
seventeen; Medical Times, London, 1851, N. S. ii. 609-612, boy aged 
fifteen; Medical Times and Gazette, London, 1884, ii. 539, child aged 
eighteen months; Ashby, a case of tuberculous mediastino-pericarditis in a 
boy aged two years, British Medical Journal, 1891, ii. 1208. 
When we consider suppurative mediastinitis we find from my paper in 
Keating’s “Cyclopaedia” that while not a common affection of childhood, 
still that, when compared with the reported adult cases, it is not an infre- 
quent disorder, as it occurred ten times out of sixteen cases of all ages. 
The symptomatic manifestations of the various affections of the medi- 
astinum somewhat closely resemble each other; all growths must interfere 
with the tissues or organs contained in one or other of the mediastinii, and 
evidences of pressure iu either the circulatory or the respiratory apparatus 
are noted in almost all cases, hence dyspnoea is usually concomitant, and 
cyanosis is frequent. 
Pain is a constant symptom, but varies in intensity; it is sometimes 
localized, or it may extend over the thorax, up the neck, and down one or 
other arm. The cervical and occipital glands may be enlarged. 
In acute mediastinal abscess, frequent flushes of heat and rigors may be 
present; pulsation may occur. Cough is usually present; emaciation 
marked. 
I have been unable to consult the original paper by Hutton on mediastino- 
pericarditis in children, St. Thomas’s Hospital Reports, 1883, London, 1884, 
N. S. xiii. 211-220. 6 
A CASE OF MEDIASTINO-PERICARDITIS IN A CHILD. 
Our book on “Diseases of the Heart in Infancy”1 contains the notes of 
a case reported by Saundby (Edinburgh Medical Journal, March, 1875, p.799), 
of a boy aged thirteen with pericarditis, pleurisy, and lung abscess, in which 
aspiration was performed in the fourth interspace, and thirty ounces of pus re- 
moved, which the writer thinks probably came from pulmonary abscess ; the 
child survived but a few hours ; and Bouchard reports a case of left pleu- 
ritis and pericarditis that is worthy of attention on account of the fact, as 
he expresses it, that two punctures of the heart occurred without accident. 
The case was tapped eight times. 
1 Diseases of the Heart in Infancy, Keating and Edwards, F. A. Davis, 1889. International 
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