In December he was often under the necessity of ejecting the contents of his stomach two or three times a day, and so enfeebled were the powers of digestion, that a cup of common gruel would induce him to make efforts to vomit. The quantity of the material discharged by the stomach was nearly equal to the amount of food taken, which rendered it conclusive, that only a very small portion of his aliment entered into the intestines. At this period his mind participated in the diseased condition of his corporeal system, and for the remainder of his sickness he laboured under extreme lowness of spirits, fully convinced, as he said, that he should never recover his former health.

His attacks of vomiting became more frequent during the months of January and February. He continued to complain of great and more uniform pain in the region of the scrobiculus cordis, where something like a circumscribed tumour was felt. He most generally ejected about half an hour after swallowing; the food thus discharged had undergone but very little alteration by the digestive process, and was mixed with some viscid matter. If he attempted to seek repose by lying on his right side, extreme nausea and vomiting were inevitable. Although his exertions to eject required no labour, yet the materials thus thrown up, were discharged with violence, in a projectile manner, and at the distance of many feet. After vomiting he experienced some few moments' exemption from distress. His bowels were obstinately costive; the urinary secretion small in quantity, and high coloured; his constitution much enfeebled, and his emaciation very considerable. Some attempts, as I ascertained, were made at this stage of his disorder, to subject his system to the action of mercury, but these attempts proved unsuccessful. Sedative medicines availed but little, and active cathartics were required to excite the intestinal canal to its wonted functions. He now had great desire for nutriment, but the anxiety he felt on account of the vomiting that was sure to take

place upon eating, induced him to make a cup of milk his principal support for the twenty-four hours.

As circumstances permitted he was occasionally visited by Dr. Hosack in the month of March, at his residence in New-Jersey: at this stage of the disease there was a regular increase in the disorder of his stomach, and his bodily and mental powers became more and more impaired. His stomach contracted upon the least quantity of aliment, whether in a solid or fluid state; he was also much annoyed with cardialgia and eructations of an acid and fœtid nature: his food was seldom retained longer than five minutes, and discharged with additional violence the quantity of the substance thrown up was greater than that of the nutriment taken in; its appearance was changed to a dark sootlike material of a fluid consistence, united with some purulent matter, and emitted an extremely offensive odour. The evacuations from the bowels, which were however very seldom procured, and then but with much difficulty, appeared to have undergone the same changes as the matter discharged from the stomach, and were said by the patient to exhibit, to a considerable degree, both in colour and consistency, the appearance of tar. Toward the close of his illness, his stomach became more retentive, and he frequently complained of excessive thirst. At the suggestion of Dr. Hosack the patient now took very small draughts of lime water and milk, which were sometimes succeeded by a few moments' relief. His bowels remained in a constipated state for more. than six weeks previous to his decease, and his only means of support were, for an equal length of time, nutritious enemata. On the morning of the 15th of April he breathed his last.

The abdominal viscera were examined six hours after death by my friend, Dr. Caspar W. Eddy. Several small whitish tubercles were seen on the surface and in the parenchymatous substance of the liver. There were no morbid appearances in the spleen, pancreas, or in the

intestines. The superior portion of the mesentery exhibited some slight marks of disease, being more than ordinarily thick, and preternaturally hard, and possessing here and there small tubercular elevations. The stomach was more than three times its common size, and was distended with a black fluid, resembling a mixture of soot and water combined with a small quantity of glutinous matter, and was particularly offensive to the smell. The coats of the stomach investing its superior curvature were greatly augmented in thickness: the cardiac portion was free from disease. A portion of the greater extremity, for about two inches round the pylorus, was in a perfectly scirrhous condition, and full one inch in thickness; a part of this thickened mass had advanced to a state of ulceration. The pyloric orifice made resistance to the passage of a common sized probe.

III. CASE of SCIRRHUS of the PYLORUS accompanied with a TUBERCULATED LIVER.

On the morning of Sunday, the 4th of June, 1815, I was requested, in connexion with Dr. William Handy, a respectable physician of this city, to examine the body of a female, aged thirty-eight years, who had died on the preceding day of a complication of distressing symptoms. On this occasion our attention was necessarily confined principally to the appearances which might be discovered in the abdominal cavity.

Not the least portion of the omentum was present. The stomach was much smaller than natural, and contained about ten ounces of a dark fluid, intimately mixed with a substance similar to coffee grounds, of a somewhat offensive smell, and seemingly acrid nature; its internal coat presented some slight marks of former inflammatory excitement,

and its whole surface was covered with a tenacious, dark coloured mucus. The most important change, however, which was found to have taken place in this viscus, was a scirrhus of the pylorus, which, from all that could be perceived, completely closed the inferior passage of the stomach, about which part, externally, was attached a tuberculated excrescence two inches in length, and half an inch in breadth, and greatly resembling, in its colour, that of a natural pancreas.

The whole of the small and great intestines manifested a perfectly sound appearance. Some few of the glands on the mesentery were larger and harder than ordinary. The spleen and the pancreatic gland were in a healthy state. It is an undertaking not altogether void of difficulty, to communicate, by words, an exact idea of the great and remarkable changes which the liver had suffered.

This organ was so much enlarged, that it occupied not only all the right hypochondrium, but also the epigastric region as low down as the umbilicus, and a very considerable part of the left hypochondriac region previously to our opening the abdominal parietes, its hardened and irregular surface could be distinctly felt under the integuments, covering the parts just noted. Both the convex and concave surface of the liver were vested with tubera: there were, probably, about sixty of these bodies on its superior surface; on the inferior surface they were more numerous. They also pervaded the inner surface of the liver, sometimes in a distinct, and at other times in a confluent form. The tubera were all of the same nature, though they varied in size: on the outer surface of the gland they preserved their distinctive form, elevated the peritoneal covering of the liver, and were sparsely variegated with red vessels in their colour they much resembled a cream white; at or near their centre they had a little depression, which presented an appearance whiter than elsewhere. In several places,

internally, these tubera closely approximated, and seemed to be adhering to each other: the largest of the inner tubera that we noticed, was three and a half inches in diameter, and upon their being dissevered by the knife, a very sinall quantity of an opake white fluid exuded from them. Upon making various sections, the substance of the liver between these tubera was always found to be less vascular, and its cohesive powers more feeble than natural.

It deserves to be stated, that, notwithstanding the enlarged and diseased condition of the hepatic organ, the gall bladder was half full of well-formed bile; that there was no effusion of water in the cavity of the abdomen, and that at no time, during a long illness, did the patient labour under jaundice.

"I believe," says Dr. Baillie, "that the large white tubercle is not so often attended with jaundice and ascites as the other."

I shall briefly relate the principal circumstances that seem to throw light on the nature of the preceding case, so far as it has been practicable to obtain an accurate knowledge of them.

The patient, from her infancy, uniformly possessed great feebleness of constitution, and for the last twenty years of her life was seldom exempt from disease. She was the mother of several living children. The complaint from which she suffered most severely, was an extreme debility of the digestive organs, which caused her to be at all times cautious in the choice of food; and to depend for alimentary support chiefly upon plain broths and milk. She was never in any degree addicted to the use of spirituous or malted liquors.

The symptoms which distinguished the irritable state of her stomach, were similar to those already mentioned in case the second, though it was only for the last two years that she suffered most remarkably on that account. She often complained of nausea, and frequently ejected her food soon after a meal. Her distress when lying down at night was