The A.B.-Z. of our own nutrition

by Horace Fletcher

The effect, therefore, even after a short period of sham feeding, stretches over a length of time. Naturally the same holds good for the taking of food in the normal way. One must, however, bear in mind that in sham feeding, with all the force and reality of a hunger sensation not satisfied, the eager desire for food, the effective agency, becomes more and more accentuated, and therefore the secretory influence is prolonged and more powerful. In normal feeding, however, the quelling of the longing, the feeling of satisfaction which, as is well known, sets in long before the termination of the digestive period from the mere filling and distension of the stomach, must diminish the desire for food, and, consequently, bring the secretory effect to an end.

It is, therefore, improbable that the whole secretory process in the stomach, which, in the case of certain kinds and quantities of food, lasts from ten to twelve hours, is dependent on the factors which we have up to the present investigated. This is all the more obvious since a sham feeding of five minutes, even under the most favourable circumstances, does not call forth a secretion for longer than three to four hours. We must, therefore, seek for other exciting agencies of the innervation apparatus of the gastric glands.

Why and wherefore is the secretion instituted by psychic influence maintained? What would first occur to all your minds is naturally the immediate influence which the food exerts upon the walls of the stomach. And this is true, but it does not happen in the simple, direct fashion current in the minds of many physiologists and physicians. When I said that bread or boiled white of egg, introduced directly into the stomach, may not for hours produce a trace of secretion, probably many of my hearers may have asked themselves with natural astonishment, “How, then, is the effect of the forced feeding of phthisical and insane patients, and the artificial feeding of those with gastric fistulæ (performed on account of stricture of the œsophagus) to be explained?” I will introduce my answer by a very unexpected pronouncement relative to the assertion that mechanical stimulation of the stomach wall by food constitutes a reliable and effective means of calling forth the secretory work of the glands. This assertion, which is so categorically set forth in many text-books of physiology, and which consequently has gained hold of the mind of the physician, is nothing else than a sad misconception degenerated into a stubborn prejudice. My own statement, repeated in many published articles, and at the meetings of various medical societies, that this dictum is only a picture of the imagination, has met, for the most part, either with an unbelieving shake of the head or else with a direct avowal that “it cannot be so.” I regret exceedingly that these steadfast unbelievers are not here, so that we might together bring the matter before the tribunal of fact, to the demonstration of which we will now proceed. To this matter I attribute very great importance. It is on this ground, according to my opinion, that the whole battle must be fought out between the generally accepted view that every agency is capable of exciting the gastric mucous membrane and the theory that it is only excitable by specific and selected stimuli. If once the defenders of the old opinion are driven from their position and obliged to admit the inefficiency of mechanical stimulation, there would be nothing further left for them than to build up new theories and search out old facts concerning gland work which have hitherto been rigidly kept in the shade. We may take it that it is mainly because people were so seized with the belief in the direct and simple mechanical explanation that Bidder and Schmidt’s experiment of the excitation of gastric secretion by mental effect has been so little taken into consideration, notwithstanding that it appeared so thoroughly reliable and convincing.

I will now repeat the experiment of mechanical stimulation of the gastric mucous membrane before you in the well-known, traditional, and classic manner. Here is a dog with a gastric fistula on which a cervical œsophagotomy has in addition been performed. I open the fistula; as you see, nothing flows out of the stomach; it was washed out clean with water an hour ago. We take the celebrated feather and also a tolerably strong glass rod. Folds of blotting-paper saturated with red and blue tincture of litmus are placed at hand. I now ask my assistant to continuously move the feather and glass rod, alternately, in all possible directions in the stomach, changing from one to the other every five minutes. On removal from the stomach each is carefully dried with red and blue blotting-paper. You have all seen, gentlemen, that this procedure has now been kept up for half an hour. From the fistular orifice not even a single drop has escaped, and, moreover, the drops of moisture on all the pieces of red blotting-paper I have been able to hand to you have assumed a distinct blue tinge, caused by the moisture of the alkaline mucous membrane. The blue pieces, however, have merely been made wet without altering their colour. Consequently, with the most thorough mechanical stimulation of the whole cavity of the stomach, we have not been able to find a single spot possessing a noticeable acid reaction. Where, then, are the streams of pure gastric juice of which we read in text-books! What objection can be raised against the conclusiveness of this experiment? In my opinion only one: that we are dealing with a dog out of health, whose gastric glands from some possible cause are unable to react normally. This single objection can be set aside before your eyes. After failing with the mechanical stimulation, we proceed forthwith to the sham feeding of the same animal. The dog takes the food offered it with keen appetite, and you see that, exactly five minutes after beginning the feeding, the first drops of juice appear from the stomach, followed by others faster and faster. I catch a couple of drops on the blue litmus paper, and you see that they produce bright red specks on the blue sheet. After thirty minutes’ sham feeding we have collected 150 c.c. of juice, which, without filtering, looks as clear and transparent as water.

We cannot, therefore, possibly doubt that, when the proper stimulus is used, the gastric glands react to it in a perfectly normal fashion, furnishing a healthy gastric juice. From this it irrefutably follows that only one explanation is to be found for the negative result in the first half of our experiment, viz., that the mucous membrane of the stomach, so far as secretory activity goes, is perfectly indifferent to mechanical excitation. And yet this mechanical stimulus is demonstrated as an exciting agency in the physiological lecture theatre. I venture to think that this lecture experiment from now onwards will quit the field, and give place to the one I have just shown you. This apparently simple experiment of mechanical stimulation can, however, only be successfully performed when certain very obvious rules are followed. These, however, physiologists have not observed, probably on account of a preconceived belief in the effectiveness of the mechanical stimulus. These rules are two. First, it is necessary that the stomach should be clean, and that nothing shall gain entry to it from without. Such conditions were not formerly fulfilled. It is true the stomach was emptied by removing the stopper from the fistular cannula, but it was not washed out till an acid reaction was no longer given, and consequently preformed gastric juice was left behind between the folds of the mucous membrane. At the same time saliva from the cavity of the mouth could gain entry, which quickly became acidified in the incompletely emptied and imperfectly washed-out organ. It is, therefore, not surprising that the glass tube, by setting up contractions of the stomach, was the means of expressing small quantities of acid fluid from the fistula-tube. (The relationship between mechanical stimulation and the motor functions of the stomach is not to be confounded with what we are here speaking of.) That matters are as I state, and that the facts correspond to the explanation is proved by this; namely, that nobody till now has obtained genuinely pure gastric juice of an acidity amounting to 0.5 or 0.6 per cent. It is only necessary to call to mind that Heidenhain, when determining the acidity of the juice first obtained from the resected stomach, was placed in no little doubt as to whether his results (0.5 to 0.6) were correct, and his assistant at the time (Gscheidlen) was set to verify the correctness of his standard solutions. The acidity of the “purest” juice known at that time was scarcely 0.3 per cent. As a further proof that none of the older observers ever really obtained a secretion from mechanical stimulation pure and simple, we may adduce the fact that none of them made mention of the constant and precise period of five minutes’ latency. To overlook this was not possible if a genuine excitation of the glands had been obtained.

Of no less importance is the second condition when we wish to perform the experiment of mechanical stimulation in the correct way. It is very necessary that the gastric glands be not already in activity at the beginning of the experiment, and also that during the experiment no impulse comes into play, which of itself, apart from mechanical excitation, could excite the glands to secretion. Nor have we any proof that observers formerly waited for hours before commencing the experiment and convinced themselves that the gastric glands had ceased working. On the contrary, we have not the slightest evidence to indicate that the authors had attempted to guard against accidental psychical stimulation of the glands—a matter which we have seen is of considerable difficulty. And some dogs are so easily excited in this way that it is almost impossible to bring their glands to rest, or at least it is necessary to wait for hours. The experimenter must strain his whole attention to preserve such an experiment free from objection. It is only necessary that some food be near the dog, or that the hands of the attendant who has prepared the food should smell of it, or that some other similar circumstance should come into play, and the glass tube, quite undeservedly, will be made answerable for the excitation of the gastric glands. As you have just seen, both of our conditions have been fulfilled on the dog before you, and the result of the experiment stands in irreconcilable contradiction to those of the laboratory and lecture experiment of former times.

The importance of the experiment, which I have already dwelt upon, justifies me in making still further demands upon your attention in order to show you two modifications of it. Nobody has as yet said, with regard to mechanical stimulation, that in order to obtain results the mechanical agency must simultaneously come into contact with numerous points of the inner surface of the stomach. But in order to meet this possible objection I will now show you two new modifications. Again a similar dog is used, that is to say, one on which both gastrotomy and œsophagotomy have been performed. The stomach has been washed out clean and is at present in a state of complete rest. Into the fistula I bring a thick glass tube containing a number of small openings (2 to 3 mm. diameter) at its rounded end. The other end of the tube is connected with a glass ball containing tolerably coarse sand. Leading into the ball is a second tube, with which an india-rubber pump can be connected and a blast of sand blown through. By rhythmic compression of the india-rubber ball I inject sand with considerable force into the stomach, and this play is kept up for ten to fifteen minutes; nevertheless, we see no trace of gastric juice. The sand falls out again between the side of the cannula and the glass tube, and it is either dry or scarcely moistened, but in no case is it able to turn blue litmus red. And yet we are here dealing with a strong and widely diffused stimulus. Look for a moment at the performance of the bellows outside the stomach. From every opening of the tube—numbering considerably more than ten—a strong stream of sand is ejected. If you hold your hand against it, you feel quite distinctly that the grains of sand strike with considerable force. And now, when our experiment is ended, we may convince ourselves by sham feeding, in easy and unquestionable fashion, that the innervation of the dog’s stomach is perfectly normal.

Yet another experiment on a similar dog. Into its empty and resting stomach an india-rubber ball is introduced. This is distended with air by means of a syringe till it is as large as a child’s head and maintained in this condition for a time, afterwards being allowed to collapse. The procedure is kept up for ten to fifteen minutes. During this time not a single drop of juice has appeared from the stomach. The surface of the ball taken out of the organ is everywhere alkaline. And here also subsequent sham feeding shows that the dog is in a suitable condition for the experiment. I must add that in making this observation the dog must not be too hungry, that is to say, must have been fed within ten to twelve hours before, otherwise a psychic excitation of the secretion can readily be induced.

If one dispassionately regards this question, and if any of our methods for the study of gastric secretion are reliable, one must be convinced step by step in the laboratory of the uselessness of mechanical stimulation. In the case of dogs with an ordinary gastric fistula, and failing some special reason, not a drop of gastric juice ever escapes from the stomach other than during the digestive period. How could this be the case if the mechanical stimulus were effective, since the inner rim of the fistula-tube is continuously in contact with the gastric mucous membrane? The same holds good for the dog with resected stomach. During the experiment a glass or india-rubber tube is brought sufficiently far into the cul-de-sac to catch the juice, and yet not a drop flows through the tube, nor does its inner surface ever become acid, so long as true secretory conditions are absent. Moreover, the tube has tolerably often to be taken out and set right.

In the ordinary gastric fistula in dogs, when the operation has lasted a long time—over a year—folds of mucous membrane are often formed in the neighbourhood of its inner orifice which completely close the tube. In these cases a long, thick, perforated metal tube has to be passed in deeply, and yet the manipulation of itself never calls forth a secretion. Further, it is a daily occurrence to find in the stomach of the dog thick rolls of hair, and yet their presence in no way hinders the arrest of the secretion, which occurs when digestion has ceased. Such an occurrence would have been specially obvious in our dog with the isolated stomach, since it was bedded with sawdust in order to guard against maceration of the wound by juice trickling out. Very often we found enormous quantities of sawdust in the stomach, as much as half a pound weight; obviously the dog had licked the wound from adherent sawdust, which it then swallowed, together with that sticking to its nose. And yet these particles of sawdust of themselves, which certainly acted as mechanical stimuli, never caused a secretion. It appears to me that this long series of facts ought to suffice to carry the supposition to its grave that by direct mechanical stimulation one is able to set the neuro-secretory apparatus of the stomach into activity.