When the disorder is severe, and the patient reduced in flesh, opiates, timely administered, are of much service in lessening the uneasiness at the stomach, and promoting sleep.

It now and then happens, that the disorder co-exists with chronic ulcer of the stomach, and that eating solid food causes pain in the stomach, which is different from the uneasiness that results from distension of the stomach, and pain also in the corresponding part of the back. In such cases, as in ordinary cases of simple ulcer, the diet should be of the least irritating kind.

By the various means which I have now enumerated, the disorder may be greatly mitigated, the strength of the patient kept up, and his life prolonged: which is as much as can be promised for any disorder which originates, as this usually does, in irremovable organic changes.-Medical Times and Gazette, Feb. 11, 1854, p. 125.

55.-A Case Illustrative of the Habitat of the Sarcina Ventriculi, and of Cardiac Murmur without Valvular Disease. By DR. T. K. CHAMBERS, (before the Harveian Society).-He said they had at St. Mary's Hospital lately an opportunity of seeing, in situ, the appearance called "sarcina ventriculi," of which he did not think an instance in the human subject had been published:-E. A. S., a girl, aged thirteen, was a patient of his in Victoria ward from August 15th to her disease, November 23rd, 1853. Her chief malady, and the cause of her death, was great enlargement of the heart, the consequence of pericarditis following slight rheumatism. This presented some points of interest peculiar to itself, to be hereinafter mentioned. But in addition to the usual inconvenience thence arising, she suffered during the last two months of her life from pain in the pit of the stomach and frequent vomiting. Temporary relief was afforded by drachm doses of hyposulphite of soda, and at another time by leaving off all food, except a mixture of equal parts of milk and lime-water. The lattér treatment seemed to give most relief, but could not be long continued or often repeated for fear of starvation. The vomit was usually acid, and consisted of food mixed with saliva and mucus; sometimes it resembled yeast. No sarcinæ could be found in it. After death there were found-1, some clotted blood in the oesophagus; 2, external congestion of the stomach; 3, in the interior of the stomach a quantity (unmeasured) of sepia-brown substance, partially attached in small flakes to the mucous membrane by a tenacious mucus, superficially transparent, but near the membrane whitish. The microscopic examination of the mucus presented an external layer formed by the abovenamed flakes, seen as yellow granular masses, a few broken starch cells, and a great number of sarcina ventriculi adhering together in masses, together with a few large granular nucleated cells, (? stomach cells.) The whitish portion of the mucus contained only the largo nucleated cells, nuclei, cylinder epithelium, and granular matter, but

no sarcinæ. A transverse section of the membrane showed the tubular structure to be perfectly healthy, and filled with nuclei and granular matter. Throughout the stomach the sarcina were found only in the superficial layer of the mucus, and not at all in the deeper one, and were always mixed with some starch-globules and other apparent débris of food. Might not the tenacity of the mucus equally spread over the membrane explain the reason why it was not rejected by vomiting?—and was not this tenacity likely to be one of the circumstances under which the organic-like forms called sarcina were produced? By this tenacity the semi-digested particles of food were retained an unnaturally long time in the stomach, and preserved from the action of the gastric juice perhaps for many days. What was more likely than that the cellular forms of vegetable life should find here a habitat such as was not elsewhere met with, and that we should find here plants (if we like to call them plants) which were not seen in other situations?

Another peculiarity worthy of note in this case was the existence of a very loud and distinct murmur with the first sound of the heart, most markedly clear at the point of impulse, and for two inches upwards, accompanied by a very decided increase in the flap-sound of the pulmonary valves. The physiological arguments for attaching this latter sign to regurgitation through the mitral valve, as given by Professor Skoda, were so rational, that he (Dr. Chambers) ventured to adopt it without the test of a crucial experiment, as an evidence that the duty of the mitral valves was imperfectly performed. Further proof of excessive impediment to the circulation was afforded during life by anasarca, albuminuria without diseased kidneys, lividity of face, and asphyxia; after death, by patches of sanguineous effusion in the substance of the lungs, and the engorgement of all the viscera with blood. Yet, on inspection of the heart, it was found healthy throughout, as far as its valvular apparatus and form was concerned. The mitral valves were artificially put together, shut perfectly, and the tricuspids as close as usual. The diameter of the pulmonary artery was one inch, that of the aorta, 075, which he should suppose was the natural proportion. The form, as he had said, was healthy, yet the organ was of enormous size, weighing no less than fourteen ounces and a half, hypertrophied and dilated in harmonious proportion, so as to be a proper heart for a gigantic man, instead of a little girl. The pericardium was pretty generally adherent inside, and in front was adherent also to the thoracic walls. What was the cause of the systolic murmur? Was it that the adhesion of the heart to the pericardium, and of that to the chest, dragged open the valve when the ventricle contracted? Such was one rational explanation in this case. But to weigh against it, he found in the St. George's Hospital fatal case-book (year 1850, folio 188), a case of a man, aged thirty-four, who died of dropsy, with degenerated liver and kidneys. Here there was a very loud mitral regurgitant murmur, and the heart was found, as in

the E. A. S., hypertrophied, dilated, and free from valvular disease, but differing in that there were no pericardial adhesions. The crucial observation, therefore, failed to establish the most obvious explanation.-Lancet, Feb. 11, 1854, p. 157.

56.-CASE OF SARCINA VENTRICULI ASSOCIATED WITH FATTY DEGENERATION OF THE LIVER.

By DR. ROBERT BARNES.

[This case is related from the necessity of proving how far this parasite may be regarded as essential, or merely incidental, to other morbid conditions in this disease.]

A lady of about sixty years of age had been addicted for many years to the free use of opium in different forms. For a long time together she consumed daily half an ounce of Battley's solution, and probably often more. She was stout, and of adipose disposition, but accustomed to exercise in the open air. Her anxiety for fresh air sometimes amounted to an uncontrollable longing; her appetite was usually good; her diet consisted generally of well-seasoned dishes-at night, of bread and milk. She suffered at intervals from "bilious attacks," which were relieved by vomiting. Of late years she had had one or two attacks in the year of an alarming character: spasms, attended by great pain in the stomach, prostration, numbness, and approach to paralysis of the right side of the body. At these times the power of speech was commonly impaired. These attacks-so severe as apparently to threaten a speedy fatal termination-gave way under the use of large doses of opium and ether. I have ordered her sometimes three grains of morphia at a dose. This was usually followed by warmth of surface, remission of pain, a rising of the pulse, a general sensation of improvement, and sleep. After this action the symptoms would abate, and under bitter stimulating tonics she would recover her usual strength. In the autumn of 1852 this lady went to Jersey, where she had a severe illness, marked by pain in the right side, for which leeches and blisters were resorted to. The cause of her illness was represented to be inflammation of the liver. My acquaintance with her previous history, and subsequent opportunities lead me to doubt the correctness of this view of the case. At any rate this illness would appear to have been much more protracted and grave than any she had previously suffered. It left her weak, with her appetite impaired: she never recovered her ordinary health.

Throughout March, 1853, she underwent excessive anxiety and fatigue owing to the illness of her husband, which terminated fatally. On the 8th of April she complained of spasms, pain in the stomach, and loss of appetite. These symptoms increased, and on the 14th the cramps and pain were intensely aggravated, and violent vomiting set in, with great mental depression. Hydrocyanic acid, ice, soda-water,

blisters to the pit of the stomach, dressed with morphia, had no alleviating effect. No sleep; pulse not quick, but full; tongue white, furred; bowels not costive; urine high-coloured. The vomited matter was at first light-coloured, containing milk, and such similar bland articles of food as she could still take. It gradually became greener; and no food but an occasional spoonful of beef-tea could be swallowed. When the vomited matter was allowed to stand, a green matter subsided forming a thick stratum. On examination this green matter was found to consist almost entirely of sarcina. Sulphite of soda was now administered in scruple doses every four hours. After thirty-six hours' use, the vomiting had abated, the last vomitings exhibiting less of the green sediment. The pain remained of the most agonizing intensity. The expression of suffering exhibited in the countenance was afflicting to witness. She begged for chloroform as an escape from her torture. The quantity of sulphite was diminished, and a mixture of infusion of quassia, bi-carbonate of potassa, and tincture of orange was added. The symptoms remitted somewhat, but the prostration increased. Breathing was distressing; she could not fill the chest, but respiration was heard in every part; the pulse was intermitting, especially after any exertion, such as sitting up in bed. Pressure below right ribs gave pain. There was no swelling of the feet or abdomen. A blister was applied to the right hypochondrium; ten grains of calomel, followed by an enema. On the 18th, Dr. Hassall saw the case with me. The symptoms were as detailed. The treatment was persisted in. On the 19th the quassia mixture seemed to compose and give relief, so much so, that it was supposed by the patient and her attendants to contain a narcotic. The appetite was somewhat improved; she took a little beef-tea. Some urine passed, and the bowels acted freely. On the 20th the distress of breathing increased; the anxiety of countenance and of manner returned. She begged for chloroform with increasing earnestness. This was administered occasionally, and was the only means by which even a temporary mitigation of suffering could be procured. The remittent character of the pulse increased; jaundice appeared; the tongue was not furred, but glazed. The treatment was continued. On the 21st she was much worse; she had vomited several times in the night; the green matter was again visible; tympanitis and some effusion in the abdomen. On the 22nd, at eight p.m., she sank. Her dissolution was preceded by a return of copious vomiting. The suffering at the stomach, and the distress of breathing and the jaundice gradually became more intense.

Autopsy on the 24th. The examination was limited to the stomach, liver, and intestines. A considerable layer of fat in the walls of the abdomen; the omentum was also very fat. The stomach was full of turbid green matter similar to that which had been so abundantly vomited just before death; some of the same fluid was also found in the duodenum. The mucous membrane of the stomach exhibited a

punctate injection, which was a little more marked towards the pylorus. The pylorus was not contracted to a sensible degree; the valvular ridge, although it felt slightly thicker than natural, was composed of nothing but normal tissues-muscular fibres and mucous membrane. The utmost that could be said was, that there was slight hypertrophy of the structures forming the valve. There was some clear fluid in the peritoneum. The peritoneal covering of the liver was free from any mark of inflammation or adhesions; it was not enlarged or contracted; the colour was pale, the aspect like that of a nutmeg; an incised surface presented a similar appearance; the texture was soft and lacerable. On a microscopic examination, scarcely a vestige of liver that could be supposed to be in a condition to fulfil its normal function could be found. It might be said with truth, that the hepatic cells in every part were full of oil. It is undoubtedly a matter for regret that circumstances prevented a more extended examination, embracing the heart, lungs, and kidneys. A careful investigation of the chest during life leads me to believe that the lungs were healthy. The urine had given no indication of granular disease of the kidney. It is not, however, improbable that there was some amount of fatty degeneration of the heart.

Confining our attention to the facts we possess, to what cause can we attribute the development of the sarcina in this case? We may fairly conclude that the sarcina did not constitute the essential morbid condition. That the administration of sulphite of soda, alkalies, and quassia was attended by a marked, although temporary mitigation of the symptoms coinciding with a diminution in the quantity of the sarcina is true. But the parasite has now been so frequently observed in connexion with an abiding organic disease that we can hardly avoid the conclusion that it is an accidental and a secondary result. The most obvious disease in the case related was the fatty conversion of the liver. This had certainly existed for a long period; and it is surprising that such extensive alteration of structure had not long before proved fatal. The slightly hypertrophied condition of the structures forming the pyloric orifice was scarcely sufficient to support the opinion of Dr. Todd, that retardation of the food in the stomach was the occasion of the development of the sarcina. The thickening observed produced no sensible contraction; nor was it observed that the stomach was unusually large.

A sufficient number of cases now exists to show, at least, this much, that the sarcina may be developed in the stomach under a variety of circumstances. Examination of the cases recorded will also, I think, render it doubtful whether any patient in whom the sarcina has been observed has ever been fairly cured. So much of the disease as might be supposed to depend upon the presence of sarcina may, indeed, appear to have been removed under the use of sulphite of soda and other treatment. But the persistence or return of certain distressing symptoms points to the conclusion that there existed some other disease.