The opinion of Schlossberger, that the appearance of sarcina is invariably an epiphenomenon, is probably correct. In every instance where the opportunity has been afforded of examining the body after death, some organic disease has been found. Thus, in Dr. Bence Jones' case, there was Bright's disease and peritonitis, but no disease of the stomach or intestines. Of three fatal cases recorded by Dr. Ransome, one exhibited granular kidneys: the stomach was enormously dilated, and around the pylorus was a dense mass of fibrous tissue which had narrowed the orifice to the size of a quill. Another showed also enlargement of the stomach; and the pylorus contracted to the size of a quill, was fixed to the liver by old and dense adhesions. There was an ulcer of the stomach. The liver was apparently healthy. In Dr. Ransome's third case, the patient died after perforation of the stomach by an ulcer. The liver was affected with medullary cancer, and was adherent to the pylorus. The pyloric orifice was large enough to admit the little finger.

I am inclined to conjecture that any cause capable of inducing obstinate vomiting may, in the end, lead to the formation of sarcina, provided the necessary acid condition of the secretions of the stomach be present. The observations of Andral, Dr. Hassall and others, clearly establish that the yeast-plant and the penicilium glaucum are apt to be developed in acid fluids containing organic matter. Dr. Neale has found both these parasitic productions present in vomited matter containing sarcina. It seems not unreasonable to suppose that the sarcina which is always found in acid fluids is as much an accidental formation as the yeast-plant and the penicilium glaucum— that this, the sarcina, like the yeast-plant and penicilium, is a symptom and indication of some pre-existing disease.

Another question is suggested by the present case. May not the vomited matter in some cases described as cases of "æruginous vomiting" have owed its green colour to the presence of sarcina? In many cases of green vomiting the colour is undoubtedly due to the presence of bile. In the case I have related, the general appearance of the vomited matter might well have justified the appellation of æruginous. Chemical tests afford the readiest means of manifesting the presence of bile: the microscope alone can afford satisfactory evidence of sarcina. In every case of green vomiting both methods of analysis should be employed.

Whether we regard the sarcina as an accident, as a mere symptom> or as an essential disease, the discovery of its occurrence in connexion with distressing symptoms which admit of more or less complete relief by the aid of agents destructive to the sarcina, must be admitted to be a valuable fact added to the stores of medical knowledge. The relation between this vegetable parasite and organic diseases furnishes one of the most interesting pathological problems. Facts are not yet numerous enough for its solution. But the diligent microscopical and

chemical investigation of the vomited matters in a large number of cases, varying in their circumstances, cannot fail to be attended with success. Lancet, Jan. 7, 1854, p. 3.

57.-ON FATTY LIVER.

By Dr. H. BAMBERGER.

Pathological Anatomy. The anatomical characters of fatty liver in an extreme case are: Increase in bulk of the organ with expansion of the surface; flattening and thickening of its borders; smooth, glistening, transparent, and tightly-stretched peritoneal covering; a a doughy feel; without and within a continuous yellowish red or pale yellowish white colour; contents of the consistence of tallow, which clings to the blade of a dry and somewhat warmed knife. A variety of the preceding is the waxy liver, which differs in presenting a deeper colour, like yellow wax, greater consistence, and a dry fracture: it is characterised by a peculiar modification of the infiltrated fat. Under the microscope there are usually seen greatly enlarged hepatic gland-cells filled with oil-globules of every size, often to that extent that the nucleus is no longer visible. Also between the cells free fat. in the form of drops, is effused. Sometimes there may be observed the peculiar radiating crystals of margarin. Of the chemical conditions of the bile in this form of disease nothing certain is known. Its visible characters do not differ materially from the normal; according to Frerichs, it is always poor in fatty matter; according to Lehmann, it sometimes contains albumen.

Etiology. The fatty metamorphosis of the organic parenchyma cells is one of the most important morbid changes to which this organ is subject. According to Reinhardt, fat molecules may be deposited, under circumstances, in all cells supplied with albuminous contents; according to Virchow, cells of a certain age contain granular fat, whose appearance usually precedes their spontaneous destruction; certain anomalies of nutrition, either of excess or deficiency, favour this degeneration, which occurs from the metamorphosis of the actual contents of the cell. In most cases of fatty liver, however, the fat does not appear to originate in the interior of the cell, but to be absorbed from without,-namely, from the blood, and to become infiltrated into the cells. This view finds support from an observation of Gulliver, that those parts which have become most diseased lie about the ramifications of the portal vein; also from the experiments of Majendie, Gluge, &c., who produced fatty liver artificially by injecting fluid fat into the blood; also by the observation of Gluge and Thiernesse, that fatty liver may easily ensue from habitual indulgence in fatty food.

Upon the bio-chemical antecedents of this disease nothing very certain is known; but there are many conditions which favour its

development. For example, want of bodily exercise; indulgence in food containing fat, or easily changed into that substance; excess in spirits, especially brandy. Under circumstances of health, the greater part of the fat obtained from the chyme enters the thoracic duct to be conveyed to the right cavities of the heart, thence to be carried to the lungs, where it serves as a material for respiration. Part of the fat probably goes by the portal vein to the liver, here to be used in the formation of the bile, a fluid abounding in carbon; so that, in the normal state, there is no excess of fat, which can become infiltrated into the hepatic gland cells. Under the circumstances of fatty disease, it appears that, either from positive excess of fat in the portal vein, or from deficient action of the lungs, or most probably from both causes combined, so much fat is accumulated in the liver, that, after the formation of the bile, the rest becomes infiltrated in the gland-cells in a molecular form. Very often fatty liver is found as an accompaniment to tuberculosis, and also, according to the author, to chronic complaints of different organs; so that he comes to the conclusion, that every protracted disease, especially when it affects respiration, favours the occurrence of fatty degeneration. Moreover, infiltration of fat accompanies the most opposite forms of chronic liver disease,— namely, nutmeg liver, cirrhosis, and cancer. Fatty liver does not occur in infancy or childhood; it is commoner among women than among men.

Symptomatology and Diagnosis.-The slighter degrees of fatty liver give rise to such trivial symptoms as not to need notice here. But even the higher forms usually produce no suffering, or such slight inconvenience as not to be associated with the real seat of disease. A patient usually feels a weight in the right hypochondrium, especially when he lies on the left side. Severe pain only ensues when the formation of fat is very rapid, and then it arises in all probability from stretching of the serous investment. There are disturbances in the digestive organs, usually attributed to other causes. In spite of this absence of strongly-marked symptoms, the diagnosis of fatty fever is, in its advanced stages, not difficult in the greater number of cases. In individuals whose mode of life favours the production of fatty liver, in those suffering from chronic diseases, especially tuberculosis of the lungs, the physician will rarely err in forming this diagnosis, when he detects an increase in the volume of the organ, both by the hand and by percussion, while there is neither pain, nor icterus, nor ascites, nor enlargement of the spleen.

As regards prognosis in its earlier stages, the disease is of secondary importance, and not likely to demand much attention. In its advanced stages it is important as connected with similar changes in other parts of the organism. The treatment can only be laid down as regards that variety of the disease which is a consequence of inactive life and luxurious habits. Such articles of food as cannot be converted into fat should be recommended, such as lean meat, green

vegetables, fruits. Spirituous drinks, too much sleep, fatty kinds of meat, &c., starch meal, and sugary substances, must be forbidden; bodily exercise and mental activity must be insisted on. Alkaline waters may be administered; also the neutral salts. In tuberculosis and chronic diseases of important organs the fatty liver is but an indication of more important changes elsewhere, and requires no particular treatment.-Med. Times and Gazette, Oct. 29, 1853, p. 458.

58.-State of the Liver in Jaundice. By DR. HANDFIELD JONES, F.R.S.-[From the history of several cases, the conclusions Dr. Jones arrives at are as follow:]

1. That interference with the out-flow of bile into the intestine causes dilatation, chiefly of the gall-bladder and larger ducts, and not at all of the smallest.

2. That this arrest of the bile-flow tend to produce local or general jaundice of the liver itself, but does not do so necessarily, or at least not for some time.

3. That local jaundice of the liver in spots, and general jaundice, as in acute yellow atrophy affecting the whole organ, may be produced without any such obstruction.

4. That any considerable accumulation of yellow pigment in the hepatic cells may be chiefly, if not entirely, dependent on vascular congestion long protracted, the exuding hæmatine undergoing changes in the liver similar to those seen when it exudes in other parts.

5. That from the comparatively small number of the coloured spots, and their often wide separation in cases of local hepatic jaundice, there seems reason to conclude, that derangement of the action of the ultimate ducts is materially concerned in their production. If this were not so, the spots ought to occur at every point where a duct terminates, as the backward pressure must tell on all alike.-Med. Times and Gazette, Nov. 26, 1853, p. 564.

59.-CASE OF DIARRHEA ADIPOSA, WITH
OBSERVATIONS.

By JEFFREY A. MARSTON, ESQ., Newcastle.

B. R., aged 35, labourer, of bilious temperament and middle stature, with a fatty frame, but a very sallow and emaciated face-came under treatment, November 1852. He complained chiefly of general debility, and a dull pain, accompanied by a creeping sensation, as if of a live animal, along the inferior part of the epigastrium to left side, and round the back to the right hypochondrium. He had also frequent purging of large quantities of a very peculiar fatty-looking substance, but in the intervals his bowels were rather sluggish, when purgatives and mercurials appeared to give him some relief, but always augmented

the discharge of this fatty matter. Some time back he had suffered from a dull aching pain in the right hypochondrium and back, extending upwards occasionally to the right shoulder. These symptoms had been gradually coming on for ten or eleven months, without apparent cause. The respiration was slow and passive, but no pulmonary disease could be detected. Heart's action was feeble, and impulse scarcely perceptible, yet no organic lesion was present, nor had he experienced dyspnoea or palpitation. There was no tenderness, swelling, or tumour anywhere, except a slight enlargement of the liver. His appetite was good, and he had a great desire for saccharine matters, fat meat, and hydro-carbons generally. Urine was passed in abnormal quantity, pale in colour, with very slight reaction on litmus: sp. gr. 1030: under the microscope it presented a few epithelial scales, and a number of oil globules; on evaporating a portion and treating it with ether, these globules were dissolved; there was less than a normal amount of urea and lithic acid, and no albumen; but Trommer's test, yeast, and oxide of silver indicated the presence of sugar, and the skin was harsh and dry, though he did not complain at all of these diabetic symptoms, all of which disappeared some time before death. Tongue was slightly furred; gums and inside of lips were pale and flabby; pulse 100, but it varied during treatment from 90 to 120. No cancer, phthisis, or cardiac affection could be traced in any of his family, which had been generally healthy.

The matters passed from the bowels presented a very fatty, tenacious, and peculiarly slimy appearance, deficient in bile, and altogether different from fæces; on raising a portion on the point of a knife it appeared in greasy masses; under the microscope numerous epithelial scales, with mucus, and a substance laden with oil globules, in every respect similar to fat, were observed: their fatty nature was rendered more evident by their being soluble in ether, and with liq. potassæ forming a semi-opaque gelatinous mass exactly resembling soft soap.

Now the questions as to the origo mali in this case were-Was the liver affected with chronic inflammation or enlarged by engorgement? Did the fault rest with the stomach, pancreas, or kidneys, or was it a case of mal-assimilation and degeneration of the tissues generally? I confess it baffled my attempts at diagnosis. He had already been under medical treatment for the last six or eight months, during which he had taken mercury and opium, been leeched, blistered, &c., without marked benefit. I advised that he should abstain from farinaceous and saccharine articles of food. Diaphoretics succeeded, though with difficulty, in producing diaphoresis; the sweat had no acid reaction on litmus. Olive oil, instead of being beneficial, only increased the discharge of fatty matter, and deranged the stomach. Purgatives, mercurials, counter-irritants, with small doses of iodide of potassium and ung. iodin. to region of liver, and a variety of other remedies failing to produce relief, at last all medical treatment was discontinued. His appetite continued good, but the adipose diarrhoea