METABOLISM IN THE STOMACH AND INTESTINES 617 



esophagus, or carcinoma of the cardia or even esophagospasm or cardio- 

 spasm may lead to marked symptoms of starvation, even resulting in the 

 characteristic starvation-death if the obstruction is complete unless the 

 condition is relieved by gastrostomy in some cases, by dilatation in others. 

 Even in vomiting of purely nervous origin with no symptoms of obstruc- 

 tion at cardia or pylorus, profound nutritional disturbances, may be met 

 with; many of these cases of so-called nervous vomiting in reality repre- 

 sent an early phase of hyperthyroidism, which later develops with its char- 

 acteristic metabolic disturbances. 



The vomiting associated with organic obstruction of the pylorus plays, 

 of course, the major role in the loss of weight and gradually increasing 

 inanition as it is impossible for food intake to be sufficient for the body 

 needs, although it is quite remarkable what marked grades of pyloric ob- 

 struction may be present with little or no vomiting, due to the compensa- 

 tory hypertrophy of gastric musculature, and aided of course by careful 

 choice of foods on the part of the patient this again varying markedly in 

 different individuals due to the different reaction of their stomachs to 

 increased work the ptotic individual being especially prone to early 

 muscle weakening, stasis and dilatation; the individual with horizontal 

 stomach with far greater powers of resistance and correspondingly later 

 development of these conditions. 



Motor insufficiency if of high grade always leads to marked nutritional 

 disturbances, loss of weight and of strength, secondary anemia of the 

 cligemic type, aggravated by the fermentative changes so frequently met 

 with in obstruction, more marked as a rule in cases where free hydro- 

 chloric acid is absent. The absorptive powers of the stomach never 

 very great are markedly diminished, while the decomposing material, 

 the large masses of bacteria, yeasts, etc., when they do reach the intestines, 

 as they must to a certain extent if the obstruction is not complete, lead 

 to inflammatory changes in the intestines with concomitant disturbances 

 in secretion, absorption and motor function. Whether certain of the strik- 

 ing symptoms sometimes met with in dilatation of the stomach tetany, 

 vertigo, etc. are due to the absorption of toxins, to mechanical causes, to 

 disturbance in calcium or chlorine metabolism with its effect on parathy- 

 roid function, to dehydration of the tissues, or to disturbance of the nerve 

 supply, cannot be definitely determined possibly all of these factors may 

 play a role. The loss of chlorides from the body may be very marked if 

 vomiting is persistent or excessive, especially in those cases with hyper- 

 secretion ; the urine besides being decreased in amount may show a marked 

 diminution in chlorides and its reaction may become alkaline, or it may 

 contain the acetone bodies in abundance, and the patient show the typical 

 symptoms of a starvation acidosis this in turn markedly increasing the 

 tendency to vomit. 



