ARTICLE IV.-Cases of Double Stomach, with Observations. By JOHN STRUTHERS, Fellow of the Royal College of Surgeons, and Lecturer on Anatomy, Edinburgh.

ON opening the abdominal cavity of a middle-aged female subject, at lecture during the winter session 1847-48, my attention was attracted by an unusual appearance of the stomach. It seemed contracted in the middle, and on distension it became evident that the stomach consisted of two sacs, connected together by a narrow communication. The accompanying woodcut will convey a better idea of its form than could be done by detailed description.

The communicating passage is just large enough to allow the forefinger to pass with ease, and the length of the constricted portion is about half an inch. On turning the stomach inside out, the mucous membrane is seen to be smoothly continuous from one cavity to the other; and, whether in the collapsed or distended state, there is no appearance of a valvular fold or thickening of the coats in the contracted part, or where it opens into either sac. The left division is fully one-third more capacious than the other, and forms a large cul-de-sac projecting in front of the œsophagus, which enters towards the upper and back part. In the sketch, which presents an anterior view, the left division is represented as twisted forwards, so as to show the place of entrance of the oesophagus, the lower part of which is naturally concealed by the prominence there appearing to lie to its left side; and this rounded prominence seems naturally to have been received into the concavity of the lesser curvature of the pyloric sac. The right or pyloric division corresponds very much to the narrow elongated form of stomach which we sometimes see, and is not much less than some adult entire stomachs of NEW SERIES.-NO. XIV. FEBRUARY 1851.

that form. The two sacs are together much more capacious than any large single stomach that I have seen. In the sketch, a small part of the duodenum is represented beyond the pylorus, the valve of which is fully formed. About three inches to the cardiac side of the pylorus will be observed a slight constriction, especially marked on the greater curvature. This corresponds to the slight constriction which usually, or at least frequently, exists at this part of the stomach. Instead of agreeing with me in regarding this case as one of true or congenital bilocular stomach, some may suppose that this state of parts may possibly have resulted from morbid action. On the one hand, that the second sac was merely a dilated portion of the duodenum, due to a partial constriction beyond, whilst the constricted part between the two sacs corresponded to or was the original pyloOr again, that the constriction was of the nature of a morbid contraction or stricture on an originally single sac. These suppositions, however, are incompatible with the facts of the existence at the right extremity of the second sac of neither more nor less than the natural pyloric thickening and projection, and the entire absence of thickening or puckering at or near the narrow part between the two sacs, as well as the absence of the least trace of old or recent disease on any part or surface of the preparation.

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Death in this case had resulted from typhus fever, and I was unable to obtain any previous history.

In my museum there is a dried preparation showing a similar peculiarity in the form of the human stomach, of which the following is a sketch:

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This preparation originally belonged to Dr Knox. For the only information I can furnish regarding it, I am indebted to Dr Lonsdale of Carlisle, formerly assistant and successor to Dr Knox, who writes to me that it was simply a dissecting-room preparation, without, so far as he is aware, any previous history.

Here, but for the constricted portion, there is less departure from the usual form of the stomach than in the former case, and in capacity the two sacs do not exceed a good sized simple stomach. The pyloric division is in this case proportionally smaller than that of the one first described, and terminates more abruptly at the pylorus,

which is seen as a well-formed nearly circular projection in the interior. On cutting into the sacs on either side of this constriction, there is no appearance of thickening or valvular projection. The orifices are smooth, and now scarcely of sufficient size to receive the little finger. On the posterior surface of the cardiac division, between two and three inches to the left of the constricted part, there is an irregular patch of thickening larger than a shilling, as if the wall had been thickened and adherent at this part. Although this thickening appears to be of pathological origin, it has no connection with the constricted part, which appears to be quite natural or healthy, as in the case just recorded.

The occurrence of a contraction about the middle of the stomach has been noticed by various anatomists. Morgagni,' in relating the post-mortem examination of a lady who had for many years been troubled with frequent vomiting, states that "the stomach was contracted, and near the antrum pylori the contraction was so much greater than in other parts, that the viscus appeared as if it had been divided into two cavities." After ascribing the symptoms in this case to other conditions, he goes on to say, "I might have supposed that the contracted state of the stomach had some influence in producing this affection had I not observed the same structure in other women, who had not been subject to vomiting. Similar contractions, too, have been discovered by other anatomists in persons of both sexes; and sometimes the aperture of communication between the two portions of the stomach was exceedingly small. Doubtless in the preceding case the contraction was congenital." Morgagni again refers in the same work to this condition, as having been noticed in several of his dissections, and observes that "the aperture of communication between the two portions of the stomach was scarcely larger than the natural extent of the pylorus." On this the editor remarks, in a note, "central contraction of the stomach is often met with; but, in general, it appears to be a temporary affection. In all the instances which have occurred to me, it was instantly removed by inflation. Sometimes, however, it is permanent; and the aperture between the two portions has been found by others as small as Morgagni has represented it above. Sir E. Home and Dr Monro have described this morbid appearance. In the MedicoChirurgical Journal for January 1816, Dr Palmer has related a case in which the contraction was as perfect as if a tight ligature had been applied, and great difficulty was found in passing the little finger through the narrow ring which separated the cardiac and pyloric portions. The inner coat seemed healthy, except at the strictured part where the coats were thickened; and adjacent to it there were some spots resembling minute granulations.'

1 The Seats and Causes of Diseases investigated by Anatomy, 1779. Edition by W. Cooke. London, 1822.

Dr Monro1 states that a contraction in the middle of the stomach has been described by Blasius, Lorry, Walter, Hufeland, and Van der Kolk, and he also notices the cases described by Morgagni. The constrictions here referred to by Dr Monro appear to have been chiefly spasmodic, and to have disappeared soon after death or on distension, since he refers, as a contrast, to one case of permanent contraction in a preparation before him, but the constriction was not greater than to give the appearance as if a cord had been "tied very slightly around the stomach."

Sir E. Home has paid particular attention to this subject, having written several papers on the structure and form of the stomach in various animals and in man. In one of these he expresses the opinion that the human stomach is divided by a muscular contraction into a cardiac and pyloric portion; that this contraction is the result of the natural action of the organ in digestion, and disappears soon after death; so that unless the body be examined within twenty-four hours the contraction will not be seen. In connection with this he gives a representation (Plate XI.) of the figure of the stomach in this condition, in which the contraction is moderate and gradual, leaving between it and the pylorus about a fifth part of the length of the organ. In a subsequent papers the same author relates a case in which, by a morbid contraction near its middle, the stomach was as completely divided as in the two cases I have related. In the drawing illustrating this case, the constricted portion has not a diseased appearance, but the contraction is described as morbid, and it is supposed that the morbid action had ensued in the part at which the physiological contractions had formerly taken place.

In describing the form and curvatures of the stomach, E. Huschke observes: Home admits, as in the stomach of the rodentia, a contraction towards the pylorus; this constriction does not always exist, and when it is present, distension with air sometimes removes and sometimes leaves it. In the first case, it arises from spasm of the muscular coat which existed during life; in the second, it is due to a contraction of all the coats of the viscus."

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M. Cruveilhier remarks on this subject : " The examples of double or triple stomachs in the human subject are merely cases of single stomachs having one or more circular constrictions. The essential character of a double stomach is not an accidental or even a congenital contraction, but a difference in structure. Bilocular stomachs, indeed, are very common; but this form (resembling that of some kind of calabash-gourds), though sometimes extremely well

1 Morbid Anatomy of the Human Gullet, Stomach, and Intestines. 1811. 2 Philosophical Transactions of the Royal Society of London, 1807, pp. 170, 171.

3 The same work, 1817, pp. 350, 351.

4 Encyclopédie Anatomique, 1845, tome v., Splanchnologie, p. 46.

5 Descriptive Anatomy, 1841, vol. i., p. 467.

marked when the stomach is empty, disappears almost entirely when it is much distended by inflation."

From the consideration of these various statements and opinions regarding constricted or double stomach, it appears that the condition chiefly referred to is that of a moderate constriction, which disappears soon after death or on distension. In a few of the cases, however, the constriction has evidently been permanent, though the want of precision in the descriptions leaves it doubtful whether the constriction was moderate or deep. In Sir E. Home's case the constriction was deep, but was regarded by him as morbid. In Dr Palmer's case, the communicating passage was very narrow, but there seems to have been thickening of the coats, and ulceration of the lining membrane at this part. It may therefore be concluded that there have been very few if indeed any instances placed on record in which the stomach was so deeply and permanently divided, independent of disease, as in the two cases I have had the opportunity of recording.

An analogy may be drawn between this condition of the human stomach, and that more especially of some rodent animals; but only in so far that there are two cavities separated by a constriction, varying in position and extent in different genera; in other respects, as regards form, position of orifices, and structure of the lining membrane, there is no correspondence. In regard to the latter point, I speak only from the appearances presented to the naked eye, the specimen in the case first related having been too old for microscopic examination; but the lining membrane of both cavities presents the same appearance, and the thickness of the walls was the same in both and at the constriction. M. Cruveilhier would regard a difference in structure as essential to constitute the case one of "double stomach." But, whilst in animals in which the stomach consists of more than one cavity, there is a difference in structure in accordance with their habits and the stages of their digestive process, I should rather expect, in the case of a division of the human stomach into two parts, not to find any difference in their lining membrane, greater at least than that which normally obtains in the microscopic structure of the cardiac and pyloric portions.

Independent of the condition of true or permanent constriction, the preceding notice of the history of this subject brings out prominently the circumstance of the occasional or frequent existence of a temporary constriction, which is worthy of notice in connection with the physiology of the stomach.

Sir E. Home is of opinion that this is the natural condition of the organ during digestion, the constriction serving the purpose of retaining the food in the cardiac division until it be prepared for farther change in the pyloric. He admits, however, that the circular muscular fibres are in no way more developed at any particular part, which we would rather expect to find were this a regularly recurring condition. In support of this view he states that he has