A CASE OF 
HOURGLASS STOMACH 
(STOMACH EN BIBS AO). 
BY 
CHARLES GREENE CUMSTON, 
Assistant Professor of Surgical Pathology in the Faculty of 
f Medicine, Tufts College, Boston ; Honorary Member of the 
Surgical Society of Belgium ; Fellow of the American Asso- 
ciation of Obstetricians and Gynaecologists ; Corresponding 
Member of the Pathological Society of Brussels, of the 
Association of Genito-Urinary Surgeons of France, of the 
Obstetrical and Gynaecological Society of Paris, etc. 
REPRINTED FROM THE 
Wetß Fortt Jfoumal 
for December 9, 1899. Reprinted from the New YorTc Medical Journal 
for December 9, 1899. 
A CASE OF UOUKGTASS STOMACH 
(STOMACH EN BISSAC). 
OPERATION. RECOVERY. 
Ex CHARLES GREENE CUMSTON, B. M. S., M. D., 
ASSISTANT PROFESSOR OF SURGICAL PATHOLOGY 
IN THE FACULTY OF MEDICINE, TUFTS COLLEGE, BOSTON ; 
HONORARY MEMBER OF THE SURGICAL SOCIETY OF BELGIUM ; 
FELLOW OF 
THE AMERICAN ASSOCIATION OF OBSTETRICIANS AND GYNAECOLOGISTS ; 
CORRESPONDING MEMBER OF THE PATHOLOGICAL SOCIETY OF BRUSSELS, 
OF THE ASSOCIATION OF GBNITO-URINARY SURGEONS OF FRANCE, 
OF THE OBSTETRICAL AND GYNAECOLOGICAL SOCIETY OF PARIS BTC. 
Miss W. S., aged forty-seven years, was first seen 
by the writer in March, 1898. At that time she was 
complaining of a severe pain in the right side and pain 
in the epigastric region and occasional vomiting after 
eating. The patient was a thin, anaemic subject, in a 
rather despondent condition of mind. Examination re- 
vealed what was believed to be a dilated stomach in a 
state of ptosis and a right-sided ren mobilis. 
On the supposition that this was a case of gastrop- 
tosis and gastrectasis, the symptoms of which were exag- 
gerated by the presence of a very movable kidney, 
nephropexy was performed a few weeks later, with the 
result that the pain in the right side was completely re- 
lieved, but the digestive symptoms continued quite as 
before. 
In November, 1898, the patient was again seen, com- 
plaining bitterly of her stomach, and a more careful 
history of the digestive disturbances was obtained, a 
Copyright, 1899, by D. Appleton and Company. 2 
A CASE OF HOURGLASS STOMACH. 
thing that should have been done in the first place, as 
the symptoms were far too marked to have been neg- 
lected as they were. 
At the age of seventeen the patient had typhoid 
fever and had suffered ever since from what she called 
indigestion; but at about the age of twenty-six attacks 
of pain in the epigastric region and vomiting began 
to occur, and have been more or less constantly present 
ever since. The attacks of gastric pain occur more es- 
pecially after a hearty meal, excessive bodily exercise, 
or mental fatigue, but at no time was any blood vomited 
or passed per rectum. 
The menses have always been regular and painless. 
Chronic constipation of severe grade has been present 
for many years, and the patient has frequent attacks 
of frontal neuralgia. The heart and lungs are normal. 
Analysis of the urine gave the following results; Spe- 
cific gravity 1.016; total amount in twenty-four 
hours = 1,300 cubic centimetres. Color pale. Reac- 
tion slightly acid. Urea, 35.5 grammes to the litre. No 
albumin nor sugar. Abdominal viscera, excepting the 
stomach, in apparently normal condition. 
I would here remark that the patient’s father 
died at the age of fifty-one of some obscure stomach 
trouble, from which he had suffered for many years. 
As has been said, a dilated stomach had been diag- 
nosticated when the patient was first seen, but we now 
suspected that the gastrectasis was quite probably due 
to a benign, or perhaps malignant, stricture of the 
pylorus, because by palpation a somewhat painful mass 
could be detected in the left hypochondriac region, 
which had not been noticed when the patient was exam- 
ined in March. The splashing sound could be elicited, 
but auscultation over the back when the patient swal- 
lowed water only showed the characteristic normal glou- 
glou sound. When the stomach had been moderately dis- 
tended with C02 its iower border was found at about 
a finger’s breadth below the umbilicus. The lower half 
of the abdomen was retracted. A CASE OF HOURGLASS STOMACH. 
3 
The vomitus obtained during an attack of pain was 
a yellow mucus with a decided acid reaction. The stom- 
ach was irrigated and a test breakfast, consisting of a 
cup of tea, one egg, and a roll, was ordered, and the 
stomach contents were withdrawn two hours later. 
They were found to be composed of fluid containing 
about twenty-five cubic centimetres of the roll. After 
filtering, the analysis showed a considerable amount of 
free hydrochloric acid and a complete absence of lactic 
acid. 
An exploratory incision was advised and accepted. 
The stomach was irrigated morning and evening 
with a l-to-1,000 solution of naphthol (3 for one week 
prior to the operation, which was done on December 2, 
1898. 
An incision twelve centimetres long was made, be- 
ginning at the outer border of the rectus muscle, mid- 
way between the tip of the sternum and the umbilicus, 
and was carried obliquely downward on the left side. 
When the abdominal cavity was exposed the pylorus was 
examined and found perfectly normal. At about the 
junction of the lower with the middle third of the 
lesser curve of the stomach was found a strictured por- 
tion uniting a normal lower third with a dilated upper 
two thirds of the viscus. The strictured portion was 
about seven centimetres wide and three centimetres 
long, and was united to the surrounding structures by 
a few tough adhesions. These were broken down by the 
finger and a few snips of the scissors and the par! 
liberated. 
After the stomach had been well drawn out through 
the abdominal incision, an incision was made on the 
anterior aspect of the viscus in the longitudinal axis of 
the strictured portion. The stenosed portion would 
allow the passage of three fingers. The incision was 
continued upward and downward for about four centi- 
metres, and when completed measured about eleven cen- 
timetres. A Heineke-Mikulicz plastic operation, as de- 
vised for the pylorus, was done, and when completed 
the line of union was about eleven centimetres long. 4 
A CASE OF HOURGLASS STOMACH. 
The borders were brought together by fourteen in- 
terrupted fine silk sutures which were passed through 
the stomach wall, but did not include the mucosa or the 
peritonaeum. The silk sutures were covered by bring- 
ing the peritonseum together with LemberFs suture of 
fine catgut. 
The peritonseum, fasciae, and muscles were sutured 
with fine chromic catgut, the skin and fat being united 
Fig. 1. 
Fig. 2. 
with aluminum and bronze wire. The two figures here 
given show fairly well the condition of the stomach be- 
fore and after the plastic operation. 
The after-treatment was simple and recovery was 
remarkably rapid. On the afternoon and evening fol- 
lowing the operation the patient vomited clots of par- 
tially digested blood. The next morning she was feel- 
ing well; temperature, 100.4° F.; pulse, 92. Vomiting 
of blood occurred in the afternoon, but the quantity 
voided was small. 
On the third morning following the operation the 
patient, who had been fed by enemata, was allowed to 
have champagne and crushed ice by teaspoonful every 
hour. Feeding per os was begun on the sixth day, and 
gradually solid food was substituted for a liquid diet, 
so that just three weeks after the operation the patient A CASE OF HOURGLASS STOMACH. 
5 
was taking meat. The patient was discharged well on 
January 10, 1899. 
I saw the patient in March, 1899, and her general 
condition was excellent. The appetite was good, the 
stomach gave her no trouble, and she had gained six 
pounds and a half in weight. 
On June Bth a letter was received stating that her 
health continued good, and that she was free from all 
her old troubles. 
B*7l Beacon Street. THE DISEASES OF THE STOMACH 
By Dr. C. A. EWALD, 
Extraordinary Professor of Medicine at the University of Berlin. 
Translated and edited, with numerous Additions, from the Third 
German Edition, 
MORRIS MANGES, A. M., M. D., 
- Assistant Visiting Physician to Mount Sinai Hospital; Lecturer on General 
Medicine, New York Polyclinic, etc. 
This work has been thoroughly revised, rearranged, largely rewritten, 
and brought up to date from the most recent literature on the subject. 
Svo. COS pages. Sold by subscription. Cloth, $5.00; sheep, $6.00. 
“In giving the medical profession this second revised translation of Professor 
Ewald’s treatise on the Diseases of the Stomach, Dr. Manges has placed the pro- 
fession under even greater obligations than we owed for the first. The first trans- 
lation was then an almost exhaustive treatise, and now, with so much new and 
valuable data added, the work is a sine 'qua non."—Atlanta Medical and Surgical 
Journal. 
“ This work as it now stands is the best on the subject of stomach diseases in 
the English language. No physician’s library is complete without it. It is in 
every way well adapted to the requirements of the general practitioner, although 
complete enough to meet also the requirements of the specialist.”—American 
Medico-Surgical Bulletin. 
“The present American edition is a peculiarly valuable one, as the editor. 
Dr. Manges, has done his work in a thoroughly creditable manner. His numer- 
ous notes, additions, and new illustrations have made the book a classic one. 
Under these circumstances it should find a place in the library of every Amer- 
ican physician, as their clientele is composed of such a large proportion of patients 
suffering from gastric complaints and more or less improper medication which 
most often ends in failure. There is no doubt that more properly directed efforts 
in the proper direction, as outlined in Ewald’s book, would soon remove from 
Americans the reputation of being a nation of dyspeptics.”—Sf. Louis Medical 
and Surgical Jountal. 
“ Dr. Ewald’s hook has met with a very cordial reception by the medical pro- 
fession. V, ithin a short period three editions have appeared, and translations 
published in England, Spain, France, Italy, and the United States. To the pres- 
ent edition the author has not only added considerable new matter, but he has 
also entirely rewritten the work. The arrangement of the chapters has been 
somewhat changed, and many new personal observations and therapeutic experi- 
ences added. The desirability of surgical interference is carefully considered, and 
the pros and cons given so far as would be necessary to enable a physician to 
determine whether the aid of the surgeon might be required. The translator has 
done his work well, and has incorporated much new matter into the text and 
footnotes. ” North American Journal of Homoeopathy. 
D. APPLETON AND COMPANY, NEWYORK.