The morbid states of the stomach and duodenum : and their relations to the diseases of other organs

Front matter

No

Boston

Medical Library

Preface

Some apology appears to be necessary in introducing a work on the Diseases of the Stomach, when so many excellent treatises on indigestion have been lately issued. There are, however, two aspects from which we may regard the morbid states of an organ. We may either view them simply as altering the anatomical structure and impairing the efficiency of the part affected ; or as * influencing other portions of the system, modifying the progress of various maladies, and giving rise to changes in the texture and functions of the different structures of which the body is composed. With the former point of view late writers have been chiefly occupied ; to the latter I am anxious chiefly to direct the attention of my readers.

The practitioner is constantly consulted for symptoms apparently unconnected with the malady with which a patient may be affected ; thus, a person whom he knows to labour under a disease of the heart or kidneys, may be habitually seeking relief for sensations indicating a derangement in the functions of the brain or stomach. And, in other cases, although the chief complaint may be of the disordered action of the organ whose structure is most notably altered,

VI PREFACE.

an imperfection in that of others may prove the main obstacle to successful treatment.

This contemporaneous affection of various organs in disease seemed to me so important, that I endeavoured to investigate microscopically the condition of all the principal structures in persons dying of different maladies. Traces of such attempt will be observed throughout this volume ; but being unable to obtain sufficient materials for such an extended investigation, I was at last obliged to limit my observations to the digestive canal. I have therefore attempted to show whether, and how often, this part of the body is affected in different disorders, and how far such affections tend to modify the course, or increase the gravity of the original malady. In treating the subject in this way, a certain amount of repetition as regards the morbid appearances is inevitable, but I trust that this will be found to be no disadvantage by those who may follow a similar line of inquiry.

Another object I have endeavoured to keep prominently in view is, how far the derangements of digestion are capable of producing morbid changes in other parts of the body. The success which has crowned the use of physical means of diagnosis, tends to concentrate our attention upon the more striking structural alterations, to the comparative exclusion of minor changes, which we are liable to regard as trivial or unimportant, although they may possess much pathological significance and practical interest. When we see an aortic aneurism or a lung consolidated by tubercle, and hear that the disease had been diagnosed at an early period, we may feel proud

PREFACE. Vll

of the certainty to which our knowledge has arrived ; but we ought not to forget that physical diagnosis only too often reveals the malady, when all hope of successful treatment has passed away.

Our chief aim therefore should be to ascertain from what causes the tubercular and atheromatous formations originally spring, and whether there may not be indications preceding their actual deposition.

Some explanation is requisite as to the manner in which the microscopical observations are described. The term "granular matter" for instance, is of such frequent occurrence, that its repetition will be probably wearisome to the reader. Nevertheless, in the description of any diseased structure it is necessary that nothing should be omitted ; and I believe that in the amorphous materials so common in most morbid products, and in the various alterations which they undergo, we may discover a clue to the origin of many diseases; for it is probable, that just in proportion as these materials deviate in character from the normal exudation, they become insusceptible of being moulded by the formative power into normal structures, and liable therefore to pathological changes.

It will be seen that I have repeatedly referred to the diseases of the lower animals, and I regret that I have not been able more fully to illustrate my subject by this means. It seems to me that comparative anatomy is as necessary to the student of pathology as to the physiologist, and that any plan of investigation which neglects it must be necessarily imperfect.

Vlll PREFACE.

Since the functions of an organ may be imperfectly performed even when its anatomical structure seems to be healthy, I have given the results of numerous experiments as to the amount of pepsin in the stomachs of persons dying from different diseases. Unfortunately I was unable to investigate the nature and the amount of the acid secreted in these cases, so that much of the value of the inquiry was lost.

It may be remarked that I have on various occasions quoted only isolated observations, when the subject would seem to require a greater number of facts. T have generally done this, in the hope of drawing the attention of others to points that I deemed worthy of further inquiry, but which I had not the opportunity of pursuing for myself.

I would take the opportunity of thanking Dr. Marston, Royal Artillery, for his very kind and valuable assistance in the preparation of this work, as well as for the various notes and cases to which his name is appended. I am obliged to the medical officers of the Middlesex Hospital, and particularly to Mr. Nunn and to other friends, for the opportunities of examining various morbid specimens, and also to Dr. Murie for some interesting examples of disease in the lower animals.

The plates are all drawn by Mr. Tuffen West from original specimens with the camera lucida. I am also indebted to this gentleman for his description of the fungus mentioned at page 254, and figured in plate 7.

31, Harley-street, Cavendish-square, March, 1868.

Introduction

Position and Relations of the Stomach

Auscultatory Percussion

Position and Relations of the Duodenum

Structure of the Mucous Membrane of the Stomach

Muscular and Peritoneal Coats of the Stomach

Structure of the Small Intestines

Composition and Properties of the Gastric Juice

Effects of Gastric Juice on different kinds of Food

Nature of the Acid in the Gastric Juice

Amount of Pepsin in the Stomachs of Persons dy

Movements of the Stomach

Digestion of Starch

Digestion of Fat

Absorption of Fat

Functions of the Intestinal Villi

Eliminating Power of the Stomach

Post-mortem Solution of the Stomach .

Methods of ExamiDing the Gastric Mucous Membrane ing of different Diseases

PAGE

Chapter II. Acute Gastritis

Reasons why the Post-mortem Appearances may be Slight Case after Scarlatina ....

Case in Kidney Disease

Case in Heart Disease ....

Case arising from Gout

48 50 52 54 55

CONTENTS.

Indigestion in Gout

Symptoms of Acute Gastritis .

Morbid Appearances

Diagnosis .

Vomiting produced by Fermentation

Acute Gastro-duodenitis

PAGE

57 58 59 60 61 63 64

Chapter III. Subacute Gastritis

Catarrh of the Stomach

Symptoms . . . .

Treatment ....

Bilious Attacks

Causes .....

Treatment ....

Fermentation in the Stomach .

Microscopical Appearance of the Vomited Matters

Subacute Gastritis from Uterine Disorders

Diagnosis of Subacute Gastritis

Irritable Stomach ....

Treatment of Subacute Gastritis .

. 68

.

. 72

. 74

.

. 76

.

. 80

.

. 84

Chapter IV. The Condition Of The Stomach In Fevers

Cattle Plague .....

Morbid Appearances of the Stomach in Cattle Plague . Inflammation of the Stomach and Bowels in Scarlatina The Effects of the Scarlatina Poison on the Stomach and Intestines Desquamation of the Epithelium of the Stomach and Intestines in

latina .....

The Condition of the Skin in Scarlatina The Cause of Albuminuria in Scarlatina Appearances in Malignant Scarlatina . The Amount of Pepsin in the Stomach in Scarlatina . The Effects of Scarlatina on Digestion . The State of the Stomach in Measles The State of the Stomach in Typhoid Fever The Condition of the Intestinal Villi in Typhoid Fever Diminution in the Amount of Pepsin in Typhoid Fever Wasting of the Mucous Membrane in Typhoid Fever . The State of the Stomach in Small Pox General Conclusions respecting Fevers

Scar

LAPTER V.

CHRONIC GASTRITIS.

ma of Chronic Gastri: . . . . 132

Inci\ seed Secret . .135

Chapter VI. F The Stomach In Dis1 - - Of Hie

HEART.

bid Appearances in t .eh . . . .147

Increased bulk of th-. -Membrane . . .145 Diniinuticn t :

iiac Dyspepsia . . . .* . 151 Embarrassment of a I I by Flatulen .

" . . . 153

Chapter VII

ON THE STATE OF THE STOMACH IN DIS lSBS ■ >F THE LIVER.

ich . _ : a of the liver . . . . . .157

I Chronic II Earlier s

n of the Portal Vein ..... 162

.R VIII.

HE DI< ORGANS IN DIABETES

inbrane unt of Pepsin in the abrane

The ( reas in I . . 171

.173

Xll

CONTENTS.

Chapter IX. Condition Of The Stomach In Disease Of The Kidneys

Morbid Appearances in the Stomach ....

Morbid Appearances in the Intestines .

Morbid Appearances in the Skin ....

Causes of the Gastritis .

Symptoms of Renal Dyspepsia ....

Treatment .......

Subacute Gastritis in Kidney Disease ....

PAGE

Chapter X. On The Condition Of The Stomach And Duodenum In Phthisis

Microscopical Appearances of the Stomach in Man

Appearances of the Stomach in the Lower Animals

Microscopical Appearances in the Intestinal Canal

State of the Intestinal Villi .

Mr. J. Hutchinson's Observations on Tuberculous Dyspepsia

Inquiries into the Symptoms preceding Phthisis

Symptoms of Tuberculous Dyspepsia

Treatment of Tuberculous Dyspepsia

Dyspeptic Phthisis

Treatment of Dyspeptic Phthisis

Conclusions respecting the Nature of Tubercle

Chemical Composition of Tubercle

Irritant Nature of Tubercle

Chapter XI. Weak Digestion

Predisposing Causes of the Disease

Exciting Causes

Diet ....

Treatment of the Dyspepsia of Old Age

211 212 215 218 221 222

CONTENTS.

Xlll

Chapter XII

ON THE CONNECTION BETWEEN AFFECTIONS OF THE BRAIN AND THE DIGESTIVE ORGANS.

The State of the Stomach in persons dying of Brain Disease

State of the Stomach in Delirium Tremens

The Symptoms of Nervous Dyspepsia

Causes of Nervous Dyspepsia .

Treatment .....

Epilepsy arising from Dyspepsia

226 227 228 231 232 236

Chapter XIII. Dilatation Of The Stomach

The Stomach liable to Degenerative Changes

State of the Stomach when Dilated

The Causes of Dilatation

Microscopical Appearances of thickened Pylorus

Causes of thickened Pylorus

Effects of Blows on the Abdomen

Cancer of the Pylorus ....

Enlarged Glands of the Pylorus a cause of Dilatation

Ulcer of the Stomach causing Dilatation

Symptoms of Dilatation of the Stomach

Diagnosis of Dilatation ....

Torula cerevisice ....

PeniciUium glaucum ....

Sarcina ventrkuli ....

Leptomitus algceformis ....

Treatment of Dilatation of the Stomach

CHAPTER XIY.

ON THE MORBID CHANGES IN THE STOMACH AND INTESTINAL VILLI PRESENT IN PERSONS WHO HAVE DIED OF CANCER.

Condition of the Stomach in Cancer of the Breast . . . 260

Amount of Pepsin . ..... 268

Relative Activity of the Pyloric and other Regions of the Stomach . 270

Condition of the Structures in the vicinity of a Scirrhous Mamma . 273

Condition of the Blood in Scirrhus .... 276

Condition of the Stomach in Cancer of the Uterus . . 276

Amount of Pepsin ...... 278

XIV

CONTENTS.

PAGE

Chemical Composition of the Gastric Mucous Membrane . . 278

The Stomach in Cancers of other parts than the Breast and Uterus . 279

State of the Intestinal Villi in Cancer .... 280 Condition of the Structures in the neighbourhood of Cancer of the

Condition of the Blood in Uterine Cancer . . . 285

The State of the Stomach not the Result of the Cancer . . 286

The Cancer not produced by the Disease of the Stomach . . 286

Both the local and general Disease connected with Degenerations of

Conclusions respecting Cancer .... 289

Analogies between Cancer and Typhoid Fever . . . 290

Chapter XV. Ulcerations Of The Stomach

Sloughing Ulcers produced by Debility

Instances in the Lower Animals

Instances in the Human Subject .

Perforating Ulcers in Young Females .

Precursory Symptoms of the Disease

Diagnosis. .....

Ulcerations accompanying Congestion Nature of Heemorrhagic Erosions .

Inflammatory Ulcers ....

Appearances in the Lower Animals and in Man . Particles of Mucous Membrane in Vomited Matters . Chronic Gastric Ulcer ....

Condition of the Blood-vessels

State of the Mucous Membrane at a distance from the Ulcer

Causes of Chronic Gastric Ulcer .

Adhesions of the Stomach ....

Causes of Death in Gastric Ulcer .

Haemorrhage .....

Treatment of Heematemesis

Perforation of the Stomach ....

Diagnosis and Treatment

Abscess of the Liver counected with Gastric Ulcer

Symptoms of Gastric Ulcer

Various Causes of Heematemesis

Physical Diagnosis of Gastric Ulcers

Vomiting of Casts of the Gastric Tubes

Vomiting of Particles of the Pancreas

Pieces of Pancreas passed by Stool

The Treatment of Gastric Ulcers .

CONTENTS. XV

Chapter XVI. Cancer Of The Stomach

Parts of the Stomach most liable to Cancer

Appearances of the Structures in the vicinity of the Tumour

State of the Mucous Membrane at a distance from the Cancer

Causes of Death .....

Symptoms of Gastric Cancer

Physical Signs of Cancer of the Stomach

Appearance of the Vomited Matters

Diagnosis of Gastric Cancer ....

Treatment .....

PAGE

Appendix

Note A. The Influence of Age upon the Production of Indigestion . 362

B. The Hereditary Transmission of Indigestion . . 365

C. The Effects of Anxiety of Mind . . . .368

D. The Influence of the Condition of the Body . . 371

E. The Effects of Imperfect Mastication . .. .374

F. The Effects of Tobacco Smoking . . . 377

G. The Use and Abuse of Alcoholic Stimulants . . 379 H. On the Deficiency and Excess of Animal Food . . 381

I. The Excessive Use of Tea and Coffee . . . 384

K. Outdoor Exercise. .... 387

LIST OF PLATES.

1. Microscopic Appearances of Muscular Fibre and Connective Tissue

during Digestion . . . . . .21

2. The Appearances of the Stomach Tubes in Cattle-plague . 88

3. Appearances of the Stomach Tubes in Scarlatina and Measles . 104

4. Appearances of the Skin and Intestine in Scarlatina . . 106

5. Appearances of the Stomach in Chronic Gastritis . . . 128

6. Intestinal Villi in Phthisis and Cancer . . . 194

7. Degeneration of Muscle in thickened Pylorus and Fungi present in

Vomited Matters ..... 244

8. Degenerations of the Stomach in Cancer of the Breast . 266

9. Appearances presented by Different Tissues in Cancer . . 284 10. Microscopical Appearances in Ulcerations of the Stomach . 312

ON THE

DISEASES OF THE STOMACH AND DUODENUM.

Chapter I

It is necessary that we should have clear ideas respecting the position, relations, structure and functions of the stomach and duodenum, if we would understand the changes produced in these organs by disease. An accurate knowledge of their position is essential for the diagnosis of many cases of ulceration and of tumour ; an acquaintance with their relations to the other viscera explains their liability to be influenced by affections of the neighbouring organs, and how their diseases tend to produce morbid actions in the structures in their vicinity ; whilst it is only by a clear perception of their healthy structure and functions that we can appreciate the alterations that result in them from disease.

The stomach occupies the left hypochondriac, epigastric, and part of the right hypochondriac regions. Superiorly it is in relation to the diaphragm and the Y b smaller lobe of the liver ; inferiorly it is separated from the small intestines by the transverse colon ; behind it lies the pancreas, whilst the spleen is attached to its most dilated part.

There is no organ so liable to changes in position as the stomach. On a full inspiration it is pushed downwards by the diaphragm, and in expiration the contraction of the abdominal muscles forces it upwards towards the chest. When empty, its lesser and greater curvatures look upwards and downwards; but when distended, they change their positions, and become respectively rather posterior and anterior.

The stomach is largely supplied with blood-vessels, nerves, and lymphatics. The arteries are derived from the coeliac axis, and their chief trunks run along the two curvatures of the organ, sending out branches on either side that perforate the outer tunics and ramify in the mucous membrane. The veins pour their contents into the vena portse. The lymphatics arise both in the sub-serous and in the sub-mucous coats, and end in a number of small glands chiefly situated along the curvatures of the stomach. It is supplied with nervous influence from the pneumo-gastric nerves, and also from the solar plexus.

By physical examination we may, in most cases, ascertain the size, shape, and position of the stomach, and its relations to many of the surrounding organs.

Palpation is chiefly useful when we have reason to suspect the presence of tumours or of ulceration. If the patient is thin and the abdominal muscles are lax, the desired information can be readily obtained by this means ; but in others, very considerable difficulty is experienced, especially in the detection

AUSCULTATORY PERCUSSION. 3

of deeply-seated tumours. When this method of examination is employed, the patient should be laid upon his back, the knees should be well raised and retained in that position, and the hand of the physician should be warmed before it is applied to the skin. In many cases, it is necessary to repeat the examination with the patient in different positions, as we may sometimes detect a deeply-seated tumour when he is in one posture which we are unable to perceive in another. As the position of the stomach is so liable to changes, we should, in doubtful cases, explore the epigastrium in full inspiration and in forced expiration ; when it is empty, and when it is distended with food.

As the stomach always contains a certain amount of gas, percussion over it elicits a tympanitic sound ; and, by a little practice, its boundaries can by this means be defined. When percussion is made over the part concealed by the liver, the stroke should be stronger than where it is only covered by the abdominal parietes. Many persons use an ivory pleximeter, but I prefer the finger, because we can better estimate the amount of resistance offered to it, as well as bring out the note produced by the stroke.

By far the best mode of defining the extent and position of the stomach is by " auscultatory percussion." I have been in the habit of using this means of examination for many years, and was not aware that it had been previously described ; but the following extract from Dr. Aitken's " Practice of Medicine" shows that it has been applied to other organs i1 — " A solid cedar cylinder, six inches in length and one inch in diameter, cut in the direction of the fibres, and

1 Aitken's Science and Practice of Medicine, vol. ii. p. 706.

b2 with an ear-piece attached, is applied to the centre of the precordial region while the ear is applied to the other end ; percussion is then made by another person from the point near where the cylinder is applied towards the limits of the heart in every direction. So long as percussion is made over the body of the heart a distinct shock is felt directly in the ear ; but as soon as the limits of the heart are passed this sharp shock immediately ceases, even in passing from one solid organ to another in contact with it, as from the heart to the liver." — Drs. Camman and Clark.

The manner in which I employ " auscultatory percussion " to the stomach is as follows. The patient being laid on his left side, so that the gas contained in the stomach may rise to the pyloric region, the cup-shaped end of a " Camman's Stethoscope" is applied to a part in the epigastrium, where, by percussion, I have ascertained that the tympanitic sound exists. I then strike the epigastrium sharply with the fingers, commencing close to the point at which the stethoscope is placed, and mark with ink the line at which the shock of the blow ceases to be felt directly in the ears. By moving the patient, so that he lies first on the back and afterwards on the right side, the gas is made to distend each region of the stomach in turn, and so the outline of the whole organ is completed. There is a chance of error if the stethoscope be placed over a dilated colon instead of the stomach ; but when there is reason to suspect that this is the case, the patient should be examined before food, and, the boundaries of the stomach having been marked out, the examination should be repeated when the organ is in a state of distension. I have often, after tracing

THE DUODENUM. 5

out the empty stomach, directed the patient to drink a little soda-water or an effervescing draught, and repeated the auscultation. Sometimes the drinking of a glass of cold water is sufficient to alter the form of the pyloric region. The cold seems to produce contraction of the muscular coat, and we can hear, through the stethoscope, the air forced onwards to the duodenal opening. In some cases, I have found even the repeated swallowing of the saliva sufficient to cause a slight increase in the size of the stomach, probably by the escape of the air contained in that viscid fluid. In others, it is necessary to unload the colon before making the examination, by an enema containing castor oil or turpentine. By the removal of flatus and fseculent accumulations, we are often enabled more clearly to define the lower boundaries of the stomach, or to satisfy ourselves as to the presence of deeply- seated tumours. It is a good plan to close the cup-shaped end of the stethoscope, by tying over it a fine piece of india-rubber, as by this means the force of the shock seems to be made more distinct.

The duodenum is a very important portion of the digestive canal, and there can be no doubt that many of the cases of dyspepsia, which we refer to disorders of the stomach, really have their origin in the derangement of the functions of this part. From its relations to the gall-bladder, the right kidney, the pancreas, and the colon, any disorder affecting it must tend to alter the functions of these organs, and thus render the symptoms of the case obscure.

Dr. Wilson Philip asserted that, in almost all long-standing cases of dyspepsia, a fulness could be discovered in the right side of the patient, which he believed to arise from dilatation of the duodenum ; but, according to my own observations, this enlargement, when it exists, is dependent on an atonic state of the colon, and not on an affection of the duodenum.

The stomach and intestines are formed of three coats : the outer, or peritoneal ; the middle, or muscular ; and the internal, or mucous membrane ; each being united with the others by means of connective tissue. We must first consider the lining membrane of the organ, as in it we most frequently find indications of disease.

When the human stomach is laid open, its inner membrane is generally found to be covered with a layer of mucus, which is believed to be^ furnished by the cylindrical epithelium that clothes the whole of its internal surface. When the mucus is removed, the membrane usually appears of a red colour, which is brightest in the middle region, and is paler near the pylorus. The* colour is most intense if death has occurred whilst digestion was going on ; in cases where much venous congestion has existed during life it presents a much darker hue, whilst, in those patients whose death has been preceded by haemorrhage, it has a pale and bloodless appearance. The thickness of the mucous membrane of the stomach is subject to great variety ; it is thickest in persons who have died suddenly from accidents, and less so in females than in males. It is often firm and dense in cases in which congestion or chronic inflammation has been present, and it is generally very thin and soft in those who have died from fever or from any lingering disease.

When the stomach is empty, the mucous membrane

THE MUCOUS MEMBRANE OF THE STOMACH. 7

presents a number of folds, chiefly in a longitudinal direction, which are effaced when the organ is distended with food. There is a very common condition, termed " mammillation," which many authors have regarded as always resulting from chronic gastritis. In this state, which is most commonly met with in the middle region, the surface is raised into small irregularly-shaped projections. When the parts presenting this appearance are examined with the microscope, the secreting tubes are often found to be distended with their contents, but presenting no distinct evidence of disease. In other cases, the structures seem perfectly healthy, and the irregularities on the surface probably result from the contraction of the muscular fibres which run between the groups into which the secreting tubes are collected.

When the surface of the stomach is . carefully examined with the naked eye, we can often recognise numerous small openings scattered over it. These are much more readily seen with the microscope, when the preparation is viewed as an opaque object. They are usually round or oval, sometimes irregular in shape, and measure from -^-^ to ai¥ part of an inch in diameter in the splenic and middle regions ; while, near the pylorus, they often attain a diameter of T^ part of an inch. In depth they are about i or i of the thickness of the mucous membrane, and when the mucus they contain is removed, three or four depressions of a circular shape come into view. These depressions are the upper ends of the secreting tubes. (See p, plate 2, fig. 3.)

The little pits just mentioned are surrounded by ridges, which separate them from each other. Sometimes, the ridges are but slightly raised, and are pale in colour ; in other cases they are very prominent, and present a plexus of vessels loaded with blood. The openings of the pits are frequently very much narrowed by the congestion of these ridges ; at other times they are so large, that the entire membrane seems everywhere studded over with minute holes. (See r, plate 2, fig. 3.)

The whole surface, both of the pits and of the intervening ridges, is covered with epithelium of the columnar variety. The separate epithelial cells adhere firmly to each other, and are attached by their smaller ends to the basement membrane, their opposite ends being free. They possess a nucleus situated near their attached end. They are stated, by Todd and Bowman, " to lie in a double series, the deeper being in course of development, while the more superficial is in the course of decay."* The truth of this statement I have been unable to verify, but it is probably correct, as we constantly find wasted, empty -looking, epithelial particles in the mucus covering the surface of the organ. (See c, plate 2, fig. 1.)

After death, the conical epithelium is generally detached, so that, at the time at which post mortem examinations are conducted on the human subject, we find the mucous membrane denuded. In some cases I have found the epithelium still adherent, especially in the pyloric region, and have seen it in the form of a thick, warty-looking mass, composed of different layers of cells. Ordinarily, the epithelial cells are intermixed with the mucus or other contents of the stomach, two or three adhering together. In other cases, they

* Physiological Anatomy, vol. ii. p. 192.

THE TUBES OF THE STOMACH. 9

present a circular or tubular form, according as they have been detached from the ridges or pits of the membrane. Care must be taken not to confound these apparent tubes with the casts that result from inflammation.

The pyloric region is at times covered with small projections like the villi of the duodenum. These have been supposed by some authors to be always caused by the secretions being forced out of the tubes by pressure incautiously applied to the preparation. There can be no doubt that such an appearance may be produced in this way, when the tubes are overloaded with their secretions ; but as I have been able, in some stomachs, to trace the basement membrane over the projections, it is probable that these elevations are often imperfectly formed villi.

When a perpendicular section is made of the mucous membrane of the human stomach, it is found that the principal part of this coat is composed of glandular structures packed together in the form of tubes. These pass perpendicularly downwards, from the pits into which they open on the surface, to a layer of connective tissue on which they rest. Each is slightly constricted shortly after its origin on the free surface of the mucous membrane, below which it gradually enlarges, and terminates in a bulb. This enlargement at its lower end is much more distinctly seen when the tube has been distended by inflammatory effusion. (See plate 2, fig. 1, and plate 3, fig. 1.)

It has been stated by some writers that the glandular structure always presents a compound tubular form at the cardia, like that which we see in many of the inferior animals. I have found this to be the case occasionally, but in the majority of dissections, the whole of the glands that contain true gastric cells are in the shape of simple tubes.

The tubes vary in length and width in different parts of the organ. Thus, taking a considerable number of measurements at random from my notebook, I find that, on the average, they were -^ of an inch in length in the splenic, ^T of an inch in the middle, and J- of an inch in the pyloric region. In each case the length was reckoned from the lower termination of the tube to the free surface of the mucous membrane. In width, the average diameter was 3^- of an inch in the splenic, -^ of an inch in the middle, and ^-i__ of an inch in the pyloric region.