eady shewn, that a certain relative quantity of caloric is essential to health, and a very different relative quantity to disease; and though each of these admits of consider ble latitude, there are, nevertheless, limited boundaries, which, if stepped over on either side, that is, too much or too little caloric, decomposition, and consequently, death must follow.

I would, therefore, urge the necessity of desisting from the process of evaporation so soon as inflammation is sufficiently subdued, at all times denoted by the absence of heat and pain, lest too little caloric be left, or what is the same thing, there be a greater abstraction of it than is consistent with health; and, if carried further, too little caloric be left to prevent decomposition, and thus be productive of gangrene.

A CASE OF AN ENORMOUS TUMOUR IN THE CAVITY OF THE ABDOMEN; BY ROBERT KINGLAKE, M.D.

Ꮵ

IT has lately occurred to me to see, in the case of a

child about three years of age, a large substantial tu'mour, situated in the epigastric region, and extending its volume throughout the greater part of the cavity of the abdomen. It appeared to originate from the inferior surface of the small lobe of the liver, at least, it was firmly attached to that part. Its weight was upwards of eight pounds, and its texture was for the most part steatomatous; some portions of it were follicular, and others of various and unequal degrees of hardness. The basis of the tumour was so narrow as to admit of its body being easily moved from side to side when pressed on, which afforded an undulating feel not unlike the fluctuating movement of a fluid. Several medical practitioners supposed it to be a clear case of ascital dropsy, and the pa tient was referred to me for my opinion as to the propriety of discharging the contained fluid by tapping. Nothing but the irretrievably lost state of the child, from the evidently enlarged size of the liver, and its emaciated and dying state, induced me to advise desisting from the operation, lest it should expedite the death of the little sufferer. In about three days after the child died, when, on opening the cavity of the abdomen, the tumour here described presented itself. It did not appear that there was any accumulation of water in the cavity of the belly. (No. 138.)

I

Had

Had the trocar been plunged into the swelling, as proposed, the deception would have been embarrassing, and would, no doubt, have occasioned additional distress to the patient.

The circumstance of there being a palpable enlargement of the liver, suggested more caution than would otherwise have been observed in treating this case as a mere dropsical affection. When visceral disease unquestionably exists, it deserves to be maturely considered in what proportion a substantial enlargement of organic parts may contribute to that bulk, which should induce suitable doubt and hesitation in concluding it to be absolutely of a fluid nature.

I remember attending a consultation on a case of supposed hydrocele, somewhat similar with respect to the nature of the tumour to the instance here recited, in the Hospital at Gottingen, under the care of Dr. Richter. The swelling was extremely bulky; on examination, it felt uniformly soft and painfully tensive. The question was, whether it was formed by an enlargement of the testicle, or an accumulation of water between its investing coats. The latter opinion predominated, and a trocar was immediately passed into it, when nothing more than a few drops of blood were returned through the canula. The consequent pain became excruciating, and the patient died within eight and forty hours. On examination after death, this ambiguous tumour proved to be a case of sarcocele, and the unsuitable treatment at least hastened the destruction of the patient.

Instances of tumefactions in visceral cavities are perhaps not frequent,* though it is clear that the accretion

of

Bonetus, in his Sepulchretum sive Anatomia Practica, has indeed recorded, among other somewhat analogous instances, the following more particularly striking examples of this disease.

Scotus dolebat in hypochondriis, lumbis, &c. Supervenit tumor circa costas nothas sinistri lateris ad os xiphoides prominens: Induruerant pancreas et mesenterium, et in molem supra modum latam, longam et cras

sam Excreverant.

"Matrone aderat tumor durus ad tactum circa mucronatam cartilagi. nem, renitens, oblongus: Gibba pars hepatis videbatur tanquam novum corpus simæ superstratum, a qua dependebat tumor oblongus instar pyri.

Vidi anno 1593, in quadam virgine juvene totum abdomen a Liene Occupatum, ipsumque ita exuberantem, ut videtur hæc virgo hydrope laho rare: Imo quod gravissimi medici in aspectu cadaveris istius mulieris dissecti, se deceptos fuisse fassi sunt: Erat molli abdomine et suffocata, quamadmodum hydrope laborantibus accidit, de vita discessit." Vide Lib. 8, Tit. de Ventris Tumore.

of new substances, under the stimulus of morbid irritation, may happen to almost any extent compatible with life. If an unusual degree of excitement should invite a proportionate supply of nutritive matter, it may be so applied and arranged as ultimately to produce excrescenecs of as large dimensions as those of the tumour which occurred in the case under consideration. That these diseased secretions often happen is very probable, and they will prove more or less destructive, according to the situ ation they may occupy, and to the nature of the neighbouring parts on which they may injuriously press. Nor is it easy either to know the existence of such tumours, or if known, effectually to counteract and prevent their progressive augmentation. It is, however, useful to be aware of the possibility of such states of disease, that when they actually occur, they may not be mistaken for others, the nature and appropriate treatment of which may be essentially different.

Taunton, June 12, 1810.

To the Editors of the Medical and Phyfical Journal. GENTLEMEN,

HAVING

AVING observed many useful observations and histories of cases of midwifery in your valuable Journal, I beg leave to transmit you the history of a case, which although it terminated fatally, will tend to shew what has been done on the subject, and point out the necessity of endeavouring to find out some more effectual means in similar cases. May the 28th. I was desired to visit Mrs. W- with all possible speed, as she was then in labour. I arrived about eleven o'clock on the forenoon of Monday. I learned she had been in labour since two o'clock on Sunday morning, but it being her first child, and she not supposing herself farther advanced in pregnancy than five months, had not called any midwife sooner, thinking her pains would subside; some of her attendants even persuaded her that it was the colic, and she had obtained some spirituous medicine with a view to relieve herself; but finding this did not answer, she was induced to send for medical aid. I proceeded to examine her, and found the membranes ruptured (which had happened a few hours before) and the

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head

head of a full grown child locked in the pelvis. The external parts were very little dilated and appeared very rigid, which I attributed to its being the first child and to her advanced age (for she was in her thirty-ninth year); the head had advanced in its natural position, and delivery seemed only prevented by the resistance of the external parts. As the pains were frequent and sharp I determined to remain with her a few hours, to ascertain what progress would be made; after which, finding no farther advance nor relaxation of the parts, I took about twelve ounces of blood from her arm and gave her forty drops of opium. This in some measure composed her between the pains, which however continued very violent. In the evening she complained of a frequent desire to make water, when the catheter was introduced and about a quart of water came away. With a view to farther relaxation, an emollient injection was thrown up, and she was ordered a pill of three grains of opium. I remained with her till twelve at night, as her throes continued much the same, and observing no farther advance, and that she was inclined to sleep between the pains, I took my leave for a few hours, desiring to be informed should any change take place.

On Tuesday morning, being still more harrassed with pain, I was called up. I again examined her, and finding that there was no farther advance, and that she was much exhausted by the continuance of the pains, I thought delivery must be attempted; and as the head was so low, the forceps appeared likely to be of service, could they be applied. At this time a continued pain of the abdomen and general soreness called for warm fomentations, which were persisted in for more than an hour, and at the same time a dose of opium was administered. This having somewhat alleviated the pain and restlessness, every thing was deferred for a few hours longer. Examining again, and observing no farther advance of the head, or dilatation, I endeavoured to introduce the extractor, which I accomplished with some difficulty, but was unable to make any progress even with it, as the rigidity of the external parts would scarcely admit of its employment. Fearing therefore lest I should irritate and inflame the parts, I made no farther attempt.

A consultation was now called, when embryotomy was proposed as the only means likely to save the mother, for there was little doubt but the child was dead, from the putrid discharge. As there was no flooding, and as the pains had somewhat subsided, it was judged advisable first

to

to give her another large dose (five grains) of opium, and apply fomentations to the external parts, with a view to relax them. This in some degree had the desired effect, but instead of producing rest, the pains appeared to come on with increased vigour, and she continued in this state till towards evening, when they again began to subside. At this time I examined, to ascertain whether those violent pains which had just subsided, had produced any advancement, when I found the head had become somewhat lower,. and the parts were more dilated. The only pain which she How felt was a general soreness of the abdomen and a de

sire to void her urine.

The patient being placed in that position in which we usually draw off the water, I endeavoured to introduce the catheter, but found I could not, on account of the advance of the head, Thinking I could now apply my hands with more effect in this position, I insinuated the fore finger of my right hand along the occiput, and the same of the left over the os frontis, and continuing an undulatory motion for a few minutes, I effected, unexpectedly, the delivery of the head, which was much facilitated by its putrid state, causing it to give way, and admitting the bones to overlap each other. The delivery of the head being thus effected, the body immediately followed in a most putrid state.

Having happily succeeded thus far, our attention was next called to the delivery of the placenta. The hæmorrhage was not very great, but her strength being greatly exhausted, and as there were no pains, it was thought advisable to delay any attempt till she recovered. The umbilical cord was in such a putrid dissolved state that it came away, separating itself from the placenta, on using the gentlest force. She now became quite easy and had several sleeps during the night.

Wednesday morning she appeared tolerably well, and had not experienced any pains since last evening. The fœtor of the discharge was so very great that a fumigating lamp was obliged to be used, notwithstanding which the nurse was seized with a diarrhoea. It was now judged necessary that the placentà should be delivered, lest she should sink under a putrid fever. 1 therefore lubricated my hand, and began to insinuate my fingers in a conical form, within the os externum, which I found at first slipped into a laceration of the right labium. This being avoided I renewed the attempt, and desiring her to direct her inspiration, and bearing down at intervals, in imitation of pains, I accomplished its introduction. The os tineæ still

13

remained