a modern conception of gastric secretory functions

~ I O R R I S O N - - A M O D E R N C O N C E P T I O N OF G A S T R I C S E C R E T O R Y F U N C T I O N S 6 1 7

7. Tanaka , K. and Tanaka , T . : J. Biochem. ( J a p . ) 18:15, 1933. 8. Foster , M. G., Hooper , C. H. and Whipple, G. H. : J. Biol. Chem.,

38:393, 1919. 9. Smyth, F. C. and Whipple, G. H. : J. Biol. Chem., 59:623, 1924.

10. Bollman, J . L. and Mann, F. C.: Am. J. Physiol., 116:214, 1936. 11. Windaus , A. : Deutsche Med. Wschr., 40:1229, 1919. 12. Schoenheimer, R., Ri t tenberg, K., Berg, B. N. and Rousselot, L . :

J. Biol, Chem., 115:636, 1936. 13. Okada, S.: J. Physiol., 49:457, 1915. 14. Specht, O.: Kiln. Wschr., 2:1046, 1923. 15. " Winogradow, A. P. : Arch. f. d. yes. Physiol., 206:590, 1924. 16. Smith, H. P. and Whipple, G. H.: J. Biol. Chem., 89:689, 1930. 17. Leites, S. and Juss in , W . : Arch. exp. Path. u. Pharmakol., 169:365,

1933. 18. Smith, H. P., Grotb, A. H. and Whipple, G. H.: J. Biol. Chem.,

80:659, 1928. 19. Weinberg, W. W. : Zentralbl. Physiol. u. Path. d. Stoffweichsel.,

6:7, 1911.

20. Loeb, A. : Ztsvhr. Biol., 56:167, 1911. 21. Whipple, G. H . : Phys. Rev., 2:440, 1922. 22. Sobotka, H. : Physiol. Chem. of Bile, Williams and Wilkins Co.,

1937. 23. Voit, C.: Ztschr. Biol., 30:523, 1894. 24. Rost, F . : Mitt. Grenzgeb. Med. Chir., 26:710, 1913. 25. Babkin : Die Aussere Sckretlon de Verdauungsdrusen. Berlin, 1928. 26. Iwanga , H . : Bet. ges. Physiol. u. exp. Path., 35:473, 1926. 27. Chabrol, E., Maximin, M. and Por in , J . : Comp. rend. de la Soc.

Biol., 100:777, 1929. 28. Beznak, A. : Biochem. Z., 210:261, 1929. 29. Licht , H . : Biochcm. Z., 153:159, 1924. 30. Kocour, E. J . and Ivy, A. C.: Am. J. Physiol., 122:325, 1938. 31. Sehmidt, C. R,, Beazell, J . M., Berman, A. L. and Ivy, A. C.:

In press. 32. Doubilet, It. : Proc. Soc. Exp. Biol. Med., 86:687, 1937. 33. Shapiro, A., Koster, It . , Ri t tenberg, D. and Schoenhelmer, R . :

Am. J. Physiol., 117:525, 1936.

A Modern Conception of Gastric Secretory Functions Based Upon Recent Investigations and Newer Interpretations

By

SAMUEL MORRISON, M.D.* BALTIMORE, MARYLAI~D

W H E N Oliver Wendell Holmes delivered his lecture on "The Contagiousness of Puerperal Fever" he

actually presented a theory supported by arguments based upon his own clinical observations as well as upon older material newly interpreted. Though much more scientific in his approach, Semmelweis could not have been more persistent than Holmes in impressing upon others his conviction with regard to the contagiousness of puerperal fever. I t must be clear to most of us that contributions to medical knowledge often come piece-meal; all the data may not fit into a harmo- nious whole but the incomplete story often becomes a probable theory. I hope to make such a contribution.

When the relationship of the stomach and pernicious anemia was discovered, a new field for the study of the gastro-intestinal t rac t was thrown open. Soon it became evident to some of us tha t entirely different interpretat ions could be placed upon older researches and that there existed in the gastro-intest inal t rac t not only an hematopoietic function but also an inti- mate motor and sensory overlapping as for example in the poorly understood phases of gastr ic secretion, which had not yet even begun to be explored.

Without a complete understanding of the normal functions of the gastr ic mucosa it is hardly possible to interpret pathological changes satisfactorily. So much of the physiology of the gastr ic mucosa is be- yond our ken that successful therapy can hardly be applied when pathologic change takes place. Now we know that there is an hematopoietic function in the cells of the gastr ic mucosa and we are constrained to ask whether there are also other functions?

GASTRIC ACHYLIA To begin then we would like to consider the subject

of gastr ic achylia. During the past 5 years we have been led to conclude that gastr ic achylia is usually relative ra ther than absolute, false than true, part ial than complete, functional than organic. I t has been the experience of most of us tha t with the introduction and utilization of the fractional test meals and hista-

•Assis tant Professor of Gastro-Enterology, Univers i ty of Maryland, School of Medicine.

Read by Title before The Amer ican Gastro-Enterological Association, At lant ic City, Tuesday, May 8, 1938.

mine many achylias proved to be more apparent than real. Fur the r observations disclosed tha t the gastr ic achylia associated with pernicious anemia was a deft- nite persistent achylia. The question arose as to whether the mechanism by which this achylia resulted was different f rom tha t associated with certain cases of gastr ic malignancy or gastri t is . Studies of this type at first led to the conclusion that the difference was one of degree, not of kind, but it was difficult to explain why pernicious anemia so rarely followed in long-standing cases of gastri t is , even to the degree of atrophy, or was so infrequently associated with gastr ic malignancy. I t appeared tha t ei ther pernicious anemia was a more general disease than could be accounted for by a gastr ic locus alone or that it came about only as the result of a combination of gastr ic changes which occurred very infrequently in instances of gastr ic achylia due to causes other than pernicious anemia.

I N T R O D U C T I O N TO N E U T R A L RED STUDIES In our clinic we have been able to observe and com-

pare the reaction to numerous test meals with and without histamine. We had adopted the usual cri terion for true gastr ic achylia, tha t is, fai lure of response to histamine. In the past 5 years we have become interested in the abili ty of the gastr ic mucosa to excrete neutral red. These studies were at first confined to animals and later included humans. However, before analyzing the results i t seems essential to remark how few observers realized the inherent possibilities of neutral red as a method of tes t ing the viabili ty of gastr ic mucosal cells. The l i terature is too abundant to summarize in this presentation but it is necessary to recall certain key studies which could be profitably reinterpreted today. For example, a careful review of many of the earlier contributions stress the almost un: believable fact that neutral red is specifically excreted by the oxyntic cell. There are dissenting observations but the consensus of opinion and the bet ter controlled experiments link together, almost inseparably, neutral red excretion with the oxyntic cell. The importance of this observation is highly significant because it immediately introduces us to a possible method of separa- t ing the stomach into various par ts for study. In other

618 AMERICAN JOURNAL OF DIGESTIVE DISEASES

words, neutral red has segregated one cell for us and it has accomplished it f a r more usefully and exclu- sively than histamine or acid secretory studies in response to test meals because, as has been and will be pointed out, it is able to detect more minute functional capacities of this cell than these other methods.

We, as well as others (1), have observed tha t pyloric resection influenced and sometimes inhibited fundus excretion of neutral red. Two possible explanations were offered, one tha t a disturbance of the magen- s t rasse caused an interrupt ion of reflex stimuli which existed between the fundus and pylorus or second, that there was a hormonal basis, the hormone having its origin in the pylorus. Klein (2) has called attention to the achlorhydria following part ial gastrectomy. This achlorhydria is due not to a loss of acid cells, as they are si tuated in the body and in the fundus of the stomach, but to a loss of the antrum, through which the chemical stimuli of the food (secretagogues) act. However, a small dose of his tamine which acts directly on the glandular cells st imulates a normal secretion of hydrochloric acid. In other words, part ial gastrectomy does not destroy the ability of the stomach to produce free acid but only interrupts the natural t ra in of events for the secondary phase of the secretion of hydrochloric acid.

The implication of all this work, in addition to the observations b a s e d on reliable investigations that pernicious anemia stomachs do not excrete the dye, is far-reaching. Neutral red becomes not only a test for t rue achylia but also a method by which degrees of impairment of oxyntic cell function may be determined and perhaps also a method of reinvest igat ing the existence of a possible pyloric hormone. The mere fact that the neutral red excretory test seems to represent the last stage of mucosal activity before complete cessation of oxyntic glandular functions is sufficient to make it replete with possibilities for studying gastr ic mucosal functions. The test is definitely independent of psychic influence as was pointed out by Henning and Jurgens (3) in a series of 161 cases. Three of their cases demonstrated no secretion of free acid af ter his tamine but a rapid excretion of neutral red.

N E U T R A L RED OUR H Y P O T H E S I S A careful consideration of neutral red studies added

to our own investigations made it ra ther clear tha t neutral red will detect more minutely than perhaps any other test including histamine whether the gastr ic mucous membrane has latent secretory and excretory possibilities. Fur thermore , and because of its selective elimination, it discloses direct information concerning oxyntic cell activity.

T H E CLINICAL DATA Henning and Bach (4) in an interest ing discussion,

concluded tha t clinically only the second phase of gastr ic secretion is studied; this held t rue for the alcohol-test breakfast , the eaffeine test breakfast , as well as Ewald's test meal. Therefore, i t is obvious, they maintained tha t only a part ial examination of gastr ic function is obtained and that no conclusions regarding the physiologic course of gastr ic secretion insti tuted by the psychic phase could be drawn. They introduced a method of s tudying both psychic and chemical phases of secretion and were able to evaluate the function of the individual par ts of the stomach. According to their modern conception of the mechanism of secretion the chemical phase of the secretion is related to the function of the mucosa of the pylorus; a direct influence by chemical stimuli of the glands of the fundus presumably does not take place. The first peak of the physiologic activity curve is no doubt con- ditioned by the parenchyma of the fundus, st imulated by the vagus. This par t of the curve tells nothing, therefore, about the functional condition of the glands of the antrum. The second rise of the acidity curve is due to the influence of the secretin on the glands of the fundus. This chemical par t of the acidity curve is based, therefore, on the function of both parenchyma segments of the an t rum as well as the fundus. From the behavior of these two segments of the acid secretion conclusions may be reached regarding the function of the mucosa of the fundus as well as of the antrum, a possibility which may be considered as a refinement of our diagnostic methods dealing with the gastro-intestinal tract. I t could be expected that by the aid of this method isolated functional disturbances of segments of the mucosa could be detected. Psychic inhibitions of the gastr ic secretion appeared at first during the first phase. This functional disturbance may be designated as functional achylia of the fundus. The isolated achylia of the an t rum is characterized by the absence of the second phase and in the presence of a psychic phase in the combined acidity curve. The isolated ant rum achylia is observed only in organic diseases.

In a study (30 cases up to the present) which we are now carrying out we have been able to corroborate the grea ter par t of these observations. We have also correlated the excretion of neutral red with these phases. In most instances we found a direct relationship between degree of acid secretion and rapidi ty of appearance of neutral red. This was especially marked in normal stomachs and in secondary gastr ic disorders. In all cases of pernicious anemia examined neither a psychic nor an organic phase could be demonstrated

Free

Total

F a s t i n g

0

4

Patient A . A .

Neutral Red 3 CC.

n t r a m u s .

M a l i g n a n t N e u t r o p e n i a

. . . . 10 Min. 20 Min. 30 Min.

0 0 0 Ewald I I [ Test

4 [ 6 I 6 ] Meal

- - y

Psychic Stimulation

WBC 1,620

30 Min.

0

4

45 Min.

0

4

Segm. 38

60 Min.

0

5

L y m . 61

75 Min.

0

5

Meno. 1

90 Min. 115 Min.

0 0

6 4

l~eutra l I Neutral Red Red

Appeared Appeared

Chemical Phase

MORRISON--A MODERN CONCEPTION OF GASTRIC SECRETORY FUNCTIONS 619

nor did neutral red appear. In a case of malignant neutropenia there was an achylia during the psychic phase as well as during the 2nd phase. However, neutral red did appear in the 2rid phase in the 90 and 115 minute specimens. We believe this signifies an incomplete a t rophy or lack of function of gastr ic mucosa which probably would re turn to function if the p r imary disease could be improved.

Interest ingly enough, some of the asymptomatic gastr ic achylias were found to excrete neutral red and we were stimulated to inquire whether the excretion of neutral red could be interpreted in terms of sufficient gastr ic function to prevent symptoms. Our data are not sufficient at present to allow us to form any definite conclusions. We have also had eases of apparent aehylia gastr iea (0-10) in which neutral red was excreted. Later these eases were found to have f ree acid and a high total acidity. We believe the excretion of neutral red indicated a possible re turn of function. All of us have had the experience of ulcer symptoms in the presence of an achylia and actual ulcers have been reported. Though the observation is debatable it has been our experience that these patients are aided by alkalies and are sensitive to acid. I t would seem that though apparent ly achylic they may later be capable of secreting their own acid. We have also had patients who demonstrated no secretion of HC1 in the fas t ing analysis or a f te r an Ewald test- meal but did excrete neutral red. Later a fractional meal showed normal gastr ic acidity. The symptoms of such patients were usually exaggerated by acid-pepsin medication.

The method of per forming the combined gastr ic function test is very simple but is omitted here to con- serve space. We used a 1% solution of neutral red (ph. 5.5) autoclaved at :15 lbs. for 20 minutes. F rom the point of view of stabil i ty we also used a 1% solution of neutral red the pH of which was adjusted to 3.5 by the addition of normal hydrochloric acid. This was also autoclaved at 15 Ibs. for 20 minutes. Both were tested bacteriologically before use. We also used the dye prepared freshly in water. However, the studies leading to the preparat ion of the dye are quite detailed and will be reported in another communi- cation.

From these clinical observations, it seems to us that neutral red will aid in diagnosing both functional and organic achylias of the fundus since its excretion depends only on the integr i ty of the oxyntic cells.

E X P E R I M E N T A L DATA The elimination of dye stuffs by the gastr ic mucosa

in various pathological conditions of the stomach and the study of this elimination experimentally in animals have received ra ther extensive recognition. However, the clinical application of this data and especially that of neutral red, has been ra ther sporadic and incomplete. In order to furnish a working basis for our investigations it seemed essential to repeat the study of dye elimination through the gastr ic mucosa (5). At present we are concerned with neutral red which we have been able to demonstrate in the oxyntic cell by a method (6) heretofore not used as f a r as we have been able to learn. This is an important contribution since the difficulty connected with the study of vital dyes is that they cannot easily be fixed in situ. I t would require too much t ime and space to review the many procedures which we carried out before we were

finally able to develop a successful fixation method and needless to say, we were at t imes skeptical of our supposition tha t neutral red which apparently finds many tissues of the body permeable could manifest selective elimination through the g a s t r i c mucosa. There can be no question, however, regarding the conclusion we have reached that the parietal cells are the cells chiefly concerned in the elimination of neutral red by the gastr ic mucosa. Moreover, Kobayashi (7) was able to show that when the parietal cells secrete HC1 in a high concentration, they secrete dyestuffs in a relatively large quanti ty; there was a parallelism between the two which was not t rue of pepsin. Henning, (8) too, by direct microscopic study concluded tha t dyestuff excretion is a function of the fundus glands, and that the an t rum glands do not par- t icipate in this function. There are, of course, dissenting views but in our work (6) we were actually able to fix the neutral red in the parietal cells, something which had not been hi therto accomplished. The stain was definitely confined to the oxyntic or parietal or acid-secreting cells.

Following a routine study of smaller laboratory animals, we decided upon the white ra t as an un- usually favorable animal for this work, (6), since the observation was made that the fundus was definitely demarcated a f t e r the injection of neutral red. The stomach, too, was small enough for fixation in its entirety.

Since the stomach is normally acid in reaction, it was decided to br ing an aqueous or saline solution of neutral red in contact with hydrochloric acid and then to add various other agents. When a precipitate formed, that combination was considered a possible means of f ixing neutral red in the gastr ic wall for most of the agents were really fixing agents. Every procedure singly and in combination used in carry ing a section through to its rest ing place on a slide was tried without success until we chanced upon the report of Pfuhl who obtained excellent results with the "Susa" mixture of Heidenhain in retaining t rypan blue. We decided to a t tempt its application to neutral red. Accordingly, the whole stomachs of rats (starved for twenty-four hours) were fixed, a f t e r the injection of I cc. intravenously of 1% aqueous neutral red, in the "Susa" mixture (corrosive sublimate 4.5 gin., sodium chloride 0.5 gm. ; distilled water 80 cc. to which was added immediately before use-- tr ichloracet ic acid 2.0 gin., acetic acid 4 cc. and formoI 20 cc.). They were then t ransfer red f rom the fixative directly to 90 per cent alcohol and during the course of the same day through absolute alcohol. (These steps are mentioned because in previous experiments the neutral red granules were dissolved out by various agents used in the fixing process. Water and the dilute alcohols were especially likely to wash out the dye). The stomachs were then carefully cut through longi- tudinally and passed into carbon disulphide (not previously used), and then into a mixture of equal par ts of carbon disulphide and soft paraffin. Af te r 8 to 12 hours in soft paraffin the halves were embedded in hard paraffin. Complete serial sections were made at 5 to 7 microns, al ternate sections being stained with phloxine-methylene blue as a control on localization of the parietal cells. The experimental sections of neutral red were carried through the alcohols, cleared, and mounted in neutral balsam. Examinat ion of these sections showed that it was possible to retain the


neutral red dye, not as a pure red but as yellowish red, which could readily be detected in the canaliculi of the parietal cells. The localization of the neutral red granules corresponds exactly with the anatomic distr ibution of parietal cells in the phloxine-methylene blue preparat ions. The same results were obtained in dogs.

Therefore, by the use of the "Susa" mixture of Heidenhain, neutral red granules were found to be selectively elimated by the parietal cells of the white ra t ' s and dog's stomachs. Since the oxyntic cell se- cretes hydrochloric acid and excretes neutral red and since both of these functions are absent in t rue achylia gastr ica it becomes clear tha t these two tests represent the most important method by which a diagnosis of t rue ach:clia gastr ica may be reached. Moreover, since the cessation of hydrochloric acid occurs long before the fai lure to excrete neutral red, as we have been able to demonstrate in animals and humans, it would appear that the HCL secretion function of the parietal cell is more sensitive to obnoxious agents than the neutral red excretory function but since many of the achylias excreting neutral red can be shown to be false the conclusion that neutral red excretion is a be t ter test of minimal degrees of parietal cell viability demands expression. Hurs t has also directed attention to the observation tha t the oxyntic are most delicate cells. To this extent, therefore, the condition of achylia gastr ica receives fu r the r elucidation.

Fur thermore , inasmuch as pernicious anemia remains the most outstanding disease of which true achylia gastr ica is a par t the question arises as to the importance of the oxyntic cell in that disease (9). i t is possible that an understanding of the function of this cell may help to make clear some steps in the mechanism of the production of pernicious anemia. At any rate, as long as neutral red is excreted by the parietal cell there is a possibility that the reaction which interfered with cell function may be reversed or reestablished. Several cases of pernicious anemia have been reported in which apparent cure has resulted. One of the more recent was described by Davidson (10). In his case the stomach regained the power of secreting hydrochloric acid and pepsin and, in all probability, intrinsic factor.

Finally not all dyes are excreted through the same channels. I t seems probable that we may look for- ward to the possibility of determining the secretory ability of various portions of the stomach on the basis of thei r abili ty to excrete dyes. Kobayashi 's observations are suggestive on this point.

A D D I T I O N A L DATA In 1934 when Dodds, Noble and Smith (11) found

that the posterior lobe of the p i tu i tary contained a substance capable of inducing a severe lesion of the acid-bearing area of the stomach and when later Dodds and Noble (12) discussed the relation of the p i tu i ta ry gland to anemia and blood format ion and reported the development of a definite severe macrocytic anemia in a certain number of rabbits t reated in this manner, it seemed possible that the problem of achlyia and pernicious anemia might be placed, at least in part , on an endocrine basis. In interpret ing their results Dodds and Noble mentioned the possibility that the control of blood destruction by the reticulo-endothelial system may be vested outside the system itself and may reside in the posterior lobe of

the pi tui tary gland. Finally, from thei r observations it seemed justifiable to them to consider the possibility of a hormonal connection between the posterior lobe of the pi tui tary gland, the stomach, and the blood picture.

With these researches in mind we asked Dr. Dodd's cooperation in an investigation of neutral red excretion of the stomach. The experiments, carried out at our suggestion by Dr. W. C. Cutting, showed deft- nitely that in rabbits both dye and acid secretion are decreased by pi tui t r in administered intravenously. Af ter the administrat ion of his tamine ( subcu tane - ously) and neutral red ( intramuscularly) a copious secretion of acid and dye result, only to be practically annulled by pi tui t r in given at the height of secretion of acid and dye. I t was demonstrated that acid and dye ran parallel, another proof tha t the oxyntic cell is concerned with the secretion of acid and excretion of dye, inasmuch as the pi tui t r in effect is specifically on the oxyntic cell.

I t would appear that these p i tu i ta ry preparat ions can produce both an achylia and a macrocytic anemia by their specific effects on the oxyntic cells. In other words, interference with secretion of acid and excretion of dye and the production of a macrocytic anemia are all the outcome of destruction of oxyntic cells. I t follows that the oxyntic cell may secrete the intrinsic factor. These results cannot be reconciled with the demonstration of Meulengracht, namely, tha t the pyloric gland region is the anatomical location of the antianemic principle. Both observations, however, can be reconciled on the basis of our conception which credits the pylorus with the possession of a hormone which acts like secretin and thus activates the oxyr~tic cell to secrete antianemic factor. In rabbits with oxyntic cell destruction produced by pitu- i tr in the pyloric excitant or hormone is present but the oxyntic cells are unable to react to the stimulus. I t does seem worthy of consideration that the potent pyloric powder of Meulengracht acts through the oxyntic cell and not directly upon the hematopoietic system.

Recently Cutting, Dodds, Noble and Williams (13) reported that gastr ic secretion is markedly altered or abolished by any factor which prevents an adequate increase in blood flow to the stomach. They conclude tha t their investigations (14) indicate that the pos- ter ior lobe of the p i tu i tary gland produces a substance which up to the present h a s not been dissociated chemically f rom the vasopressive principle, and which is necessary for maintaining the vascular system in such a state that it is capable of a smooth and regular activity, so that the blood flow to secreting glands such as the stomach may be co-ordinated with the secretion, following the application of an adequate stimulus. They believe their findings demonstrate a new relationship between the posterior lobe of the pituitary, the blood flow, and al imentary secretion; and they suggest an entirely new approach to research on disease in which there is a derangement of the al imentary function. Interest ingly enough, Cannon has called attention to an achylia result ing f rom deficient blood supply incident upon st imulation of the sympathetics which in turn caused a contraction of the splanchnics.

CONCLUSION As the result, therefore, of a careful consideration


of neutral red studies added to our own investigations it seems ra ther clear that neutral red will detect more minutely than perhaps any other test including histamine whether the gastr ic mucous membrane has latent secretory and excretory possibilities. Fur ther - more, and because of its selective elimination, it discloses direct information concerning oxyntic cell activity.

GASTRIC MUCOSA-HEMATOPOIETIC F U N C T I O N S

Few investigators actually realized that the gastr ic mucosa played so important a role in hematopoiesis until the researches of Castle were so convincingly carried through. These "opened a sesame" which led to many fine contributions and hypotheses. However, there were many cases of pernicious anemia which could not be explained for one reason or another on the principles laid down by Castle and others. Many theories were offered. Among them I called attention (15) to the fact that a Meckel's diverticulum occasionally contains the same cell elements which are present in the stomach and arguing by analogy it seemed perfectly logical to suppose that aberrant gastr ic tissue may be present in other par ts of the body. Such heterotopic tissues are already famil iar to us not only in Meckel's diverticulum but also in the esopha- gus, pancreas and intestine. Before this Association at its meeting in May 1936, Minor considered plausible my suggestion that the gastr ic factor is perhaps also secreted by aberrant gastr ic tissue as in Meckel's diverticulum. I f this is worth consideration we may argue by analogy t h a t t h e constant presence of gastr ic achylia is hardly co-incidental in pernicious anemia. Of course it is possible tha t because gastr ic achylia is present gastr ic digestion is unable to elaborate f rom food the specific antianemic principle present in liver but it is also possible tha t the fai lure of the gastr ic mucosa to elaborate intrinsic factor is the result of the same process which causes gastr ic achylia. Moreover, the duodenum and possibly other par ts of the digestive system also play an important par t in pernicious anemia. In this instance a duodenal achylia may in ter rupt the elaboration of an antianemic substance. However, we have not been able to demon- s t rafe such an achylia so that it is possible tha t the fai lure to elaborate the antianemic factor may simply be due to functional or organic dysfunction of the specific cell concerned in its elaboration. I t would seem as Braun (16) concluded, tha t the hormone which is active in pernicious anemia is produced by both the gastr ic and duodenal mucous membrane of normal persons. The work of Meulengracht would also lead to the same belief except that his demonstration of the antianemic potency of pyloric gland substance seems hardly capable of explaining many cases of pernicious anemia. Meulengracht and Schiodt (17) found con- siderable pepsin and rennin activity in the preparations f rom the fundus and little in those f rom the cardiac and pyloric portion of the stomach of swine. They concluded tha t pepsin and rennin are probably secreted by the fundus glands only and they established physiologic and anatomic dissociation between pepsin and the antianemic factor in the stomach. Greenspon's work (18) although not substant iated in its major claims, demonstrated the antagonism of pepsin toward the antianemic factor. But pepsin is secreted for the most par t f rom the oxyntic cells of the stomach and

estimates are given of f rom 25 to 80 times the secretion of pepsin by fundus cells as compared to pyloric cells. In fact some observers doubt any actual secretion of pepsin f rom pyloric cells.

Now we come to a major theory which I hesitate to present. I t runs thusly. We have independently been able to demonstra te that neutral red is eliminated selectively by the oxyntic cell of t he stomach. I t has also been shown that its quanti tat ive excretion not infrequently runs parallel to hydrochloric acid secretion and tha t it is influenced by the pylorus. Since pepsin tends to inactivate or antagonize antianemic factor it would seem to be poor bodily economy to have it secreted by peptic cells; moreover, since failure to secrete hydrochloric acid and excrete neutral red, both concerned with oxyntic cell viability, determine the existence of t rue achylia and since without t rue achylia t rue pernicious anemia can hardly be presumed to exist, is it not logical to inquire into the possible role which the oxyntic cell plays in pernicious anemia.? Even though complete gastrectomy may not be followed consistently by pernicious anemia it has occurred. Of more importance are three other factors: (1) the difficulty of excluding all oxyntic cell tissue as is shown by the recurrence of acid secretion a f te r gastrectomies of various degrees, (2) the plausibility of the existence of aber ran t gastr ic tissue and thirdly, the t ime factor, namely, how long does it take to develop pernicious anemia? The lat ter undoubtedly depends upon the diet and vicarious intestinal digestion as well as the amount of antipernicious anemia factor already stored up.

In other words, we must investigate the gastr ic mucosal functions f rom the point of view of specific cell activity. To this end, we set out to pe r fo rm a group of experiments based on the possible presence of a pyloroduodenal hormone and another group which would test the likelihood of the pepsin-inactivating theory on the antianemic factor. We had in mind two possible hypotheses. The first supposed tha t if a pyloro-duodenal hormone existed then the effect of pyloric-gland substance as reported by Meulengracht could hardly be directly potent but must act upon some other substance to produce secretion of antianemic factor much as secretin acts. The second supposed that i f depepsinized fundus could be shown to have antianemic propert ies then the oxyntic cell must be reconsidered as a potent source of intrinsic factor.

HORMONE. OUR H Y P O T H E S I S Exper iments (19) w i t h various pyloric extracts

suggest that a pyloric secretion may exist and the conception is offered that a composite pyloroduodenal hormone may part icipate in the elaboration of intrinsic factor as well as hydrochloric acid. The belief is also expressed that the hormone may contain histamine as one of its constituents but does not depend upon histamine alone for its several functions. An hypothesis w o r t h y of fu r ther investigation would credit the pyloroduodenal mucosa with the elaboration of a hormone which stimulates the secretion of an intrinsic factor by the gastr ic glands which, in turn, acts on food materials to produce substances that prevent pernicious anemia.

THE CLINICAL DATA As a result of our previous studies the idea sug-

gested itself to us tha t the pylorus (and duodenum)


may be the possessor of a hormone which forms the act ivat ing or releasing stimulus for secretion of the "intr insic factor of Castle." In the past others have called at tent ion to a pyloric (duodenal?) hormone, gas t r in by name, which was thought by some investigators, to be fundamental ly important in producing one phase of the gastr ic secretory cycle. Since these studies appeared before Castle's contributions to the elucidation of the mechanism of pernicious anemia, the proof of the degree of potency of pyloric extracts was judged pr imar i ly by the amount of acid their adminis t ra t ion stimulated. Even with so definite an indi- cator the conclusions reached by different groups of invest igators were in conflict. I t has recently been suggested by us (19) tha t the gastr ic hormone (pylorus, duodenum) may be associated w i t h t h e intrinsic factor. As a prel iminary approach to the problem we decided to make pyloric extracts using acid secretion as a numerical measure of thei r potencies and hoping to correlate acid secretion with intrinsic factor secretion, for it was our conception that a composite pyloro-duodenal hormone which stimulated acid secretion may possibly st imulate antianemic, intrinsic factor, secretion. These increased secretions could be therapeutically tested in swine with macrocytic anemia produced by the method of Rhoads. This is an excellent and tremendous field of research which figuratively begs all of you to enter it.

Many workers are of the opinion that the pyloric hormone is identical with his tamine but in reviewing the evidence in favor of and against the existence of a pyloric hormone one is left r a ther in doubt, not only as to its identi ty with his tamine but also as to its existence. There is no question but that Meulengracht 's recent contribution (20) seems to have demonstrated tha t the pyloric gland region has antianemic potency but it is important to recall the older researches of Lim (21). Lim believed it probable tha t by adopting different methods of extraction the order of potency of pyloric, cardiac, duodenal, fundic, jejunal and ileal extracts could be so altered as to obtain results s imilar to those of Popielski who found fundus extracts to be as active as those of the pylorus in s t imulat ing digestive secretions. Consideration of this belief in the light of Greenspon's work as well as in the light of some of our own researches now in progress, suggest a whole new field of gastr ic physiology. Moreover, on the basis of anatomical s t ructure alone the fact that fundus and pylorus extracts may have equal potency must at least suggest tha t the i r mechanisms of activ- i ty differ.

Ivy (22) has reported tha t an acid extract of the pyloric mucosa, when injected hypodermically, stimulates gastr ic secretion. Crystalline histamine has been isolated f rom such an extract and Ivy believes tha t the evidence indicates tha t it is the sole secretory excitant of such extracts ; tha t is, gas t r in and histamine appear to be identical. However, it seems clear to most of us that his tamine is not known to be a s t imulator of intr insic factor secretion and it would seem plausible to consider tha t a gastr ic hormone w h i c h h a s this proper ty must be something other than histamine or something in combination with histamine.

There is another interpretat ion of Meulengracht 's work which possibly offers a more consistent explanation of the various results obtained, especially in the light of our neutral red experiments. I t is possible, for example, tha t the effect obtained a f t e r feeding

pylorus powder is due to the activation of oxyntic cell to secrete its contents which may perhaps include intrinsic factor ra ther than to the supposed presence of intrinsic factor in the pylorus powder. The absence of excretion of neutral red in pernicious anemia stomachs demonstrates in my opinion, not only a fai lure of fundus secretory activity but also a fai lure of the normal act ivat ing stimulus supplied by the pylorus. In other words, this is a mechanism which we know already exists in the human organism as demonstrated in the mode of action of pancreatic secretin. I f the fundus plays only a secondary role in pernicious anemia it would be difficult to explain the remarkable consistency of achylia as well as the occasional changes observed in the microscopic studies of oxyntic cells. On the other hand, if duodenal, pyloric and cardiac powders are in reali ty act ivat ing substances for fundus gland secretion an explanation is possible of certain cases in which acid secretion and intrinsic factor secretion have been known to return. This explanation includes the p r o b a b l e fact tha t neither pyloric gland region nor fundic gland region were entirely atrophied. In other words, both were ready to function when properly treated. I t seems possible, therefore, that pernicious anemia is not an incurable disease, that it is, moreover, curable if the t rea tment changes f rom substi tution therapy to a type of therapy the purpose of which is to s t imulate pyloric gland activity of the affected individual. Such therapy may include the administrat ion of pyloric g l a n d powder temporar i ly not only as substi tution therapy but also as st imulative to the pyloric gland region which in the meant ime must be relieved of any local lesion which interferes with its activity. The outlook is more optimistic than in diabetes because oral t reat - ment is effective and the pyloric gland region is so widespread probably including many aber ran t rests which make it al together likely that proper st imulation will br ing enough of them into activity to result in the cure of the disease. I t is also not impossible to conceive that the pyloric (including duodenal) hormone or even histamine or some similar preparation is the key to the cure of pernicious anemia. I f Meulengracht 's work is to be interpreted as it is in his article, then in cases of pernicious anemia the pylorus and duodenum may be expected to show some organic or perhaps some detectable functional impairment of secretion. However, reports of histological studies of the stomachs in cases of pernicious anemia, i f report- ing any change at all in the stomach, usually stress oxyntic cell changes.

That the appearance of pernicious anemia may not be an irreversible reaction is suggested by a number of observations. Castle (23) has pointed out tha t the deficiency of the gastr ic factor is apparent ly the domi- nant mechanism in Addisonian pernicious anemia in relapse. He believes it probable, however, that the gastr ic defect is relative ra ther than absolute. Gold- hamer (24) has demonstrated tha t the intrinsic fac tor of Castle is present in pernicious anemia stomachs but in decreased amounts while Castle and Minor (25) suggest tha t the existence of residual amounts of intrinsic factor probably explains the "spontaneous" remissions sometimes former ly observed, especially under optimal nutri t ional conditions with high-protein feeding. Castle, Heath and Strauss (26) have demonstrated the recrudescence of gastr ic fac tor in one patient a f ter t rea tment with liver extract. Such was

MORRISON---A MODERN CONCEPTION OF GASTRIC SECRETORY FUNCTIONS 623

also apparent ly the case in the patients observed by Barne t t (27). This observation probably explains the response of occasional patients with pernicious anemia to the oral administrat ion of extrinsic factor, espeei- ally of autolyzed yeast in large amounts. Castle (23) also calls attention to the demonstrat ion of the re- erudescence of intrinsic factor in a pat ient with pernicious anemia who originally secreted f ree hydrochloric acid without intrinsic factor in the gastr ic juice. Strauss and Castle (28) point out that at least in some instances of pernicious anemia of pregnancy the administrat ion of extrinsic factor before delivery may produce no effect upon blood formation. Af ter delivery, however, this mater ial may induce clinical improvement and a reticulocyte response which may then be augmented when normal juice is added. The disappearance of the intrinsic factor of the gastr ic juice during pregnancy is occasionally paralleled by the disappearance of the hydrochloric acid, which like- wise may re turn af ter the bir th of the child.

Suggestive also is the report of Schiff and Tahl (29) that the oral administrat ion of single doses of desiccated hog's stomach stimulates the secretion of free hydrochloric acid in normal persons and in patients with hypochlorhydria and apparent achlorhydria. The prolonged administrat ion of desiccated hog's stomach in cases of genuine achlorhydria or achylia gastr ica may cause the disappearance of symptoms without the re turn of free hydrochloric acid.

E X P E R I M E N T A L DATA In our work (19) pig 's pyloric extract was used on

dogs but inasmuch as there are conflicting opinions regarding the presence of the anti-anemic factor in the stomach of a dog the interpretat ion of some of our findings must be made with care. Nevertheless, Morris and his coworkers (30) have found dog's secretion potent insofar as hematopoietic activity is concerned.

The methods of preparat ion of our extracts f rom the pylorus mucosa of the hog's stomach have already been published (19). The extracts were divided into 4 portions as follows: supernatant and precipitated sodium hydroxide portions and supernatant and precipitated hydrochloric acid portions. The original combined alkaline portions were tested pharmacologically and no depressor substances were found whereas the acid portions contained the equivalent of .0004 mg. histamine per 1 cc. Later determinations of other preparat ions disclosed that NaOH and HC1 super- na tant contained histamine-like substances whereas NaOH precipitated portion did not contain any depressor substances. Our HC1 precipitated portion was not sat isfactory; the observations were few and in- conclusive. Histamine controls were used throughout these observations. NaOH (S) was found to st imulate gastr ic acidity. I t may be supposed that this is due to i ts his tamine content but on the other hand, the HC1 (S) as prepared by us, was impotent. The activity of NaOH (S) developed on standing 10 days. No potency was present before that t ime even when administra- tion was performed intraperi toneally and intravenously. A t rypsin odor developed a f t e r 10 days but t ryps in controls ruled out any par t which it may play.

These experiments have as their object the discovery of a possible active principle in pyloric extracts prepared by the method described. Since gastr ic acid t i t ra t ions give quant i ta t ive readings, tha t index was used to detect any potency of the extracts. Thus far ,

t h e r e is sufficient evidence to st imulate fu r ther investigation of the supernatant alkaline extract. This portion of the extract was found to contain histamine- like substances but its act ivi ty appeared a f te r a period of delay during which there developed a t rypsin odor. This odor was found not to be due to t rypsin activity and it could not be due to peptic activity since it developed when the pH was 7.8. I t is possible that sufficient enzyme was present to break down a protein and release a hormone and it seems to us that this period of delay allows for the liberation of precisely such an active hormone which may contain histamine but is ra ther a composite hormone capable of s t imulat ing not only acid and pepsin but possibly also intrinsic factor. Fours, Helmer and Zerfas (31) believed tha t during their procedure of concentration by vacuum distilla- tion, a hormone was released or activated.

This data does not refute the assumption that there may possibly be a pyloric hormone which operates as does pancreatic secretin. Pyloric gland therapy may simply be replacement therapy but it may, a f t e r its absorption, also stimulate oxyntic cells to secrete intrinsic factor. Fur thermore , it is worth considering whether the oxyntic cell is capable of two types of secretion, one an acid secretion which is external in nature, the other an intrinsic factor which may be pr imar i ly an internal secretion although it obviously also appears in the gastr ic juice.

The author realizes that this par t of the work is in- conclusive at its present stage of development but it at least suggests an approach to the demonstrat ion of a pyloro-duodenal hormone. All previous researches on gastr ic hormones should be repeated and re-interpreted on the basis of the newly discovered hematopoietic functions of the gastro-duodenal region. We suggest that a pyloroduodenal hormone could have the same "double play" characterist ics of the pancreatic hormone, secretin, which is formed by the epithelial cells of the duodenum under the stimulus of acid contents f rom the stomach, and only then is available to excite pancreatic secretions. Similarly, who knows but that the pyloroduodenal hormone may stimulate the oxyntic cells to secrete the intrinsic factor (also, but perhaps incorrectly, called addisin). We do not believe a pyloroduodenal hormone could be the intrinsic factor for in tha t case too, many inexplicable problems would arise, but if it were the "sine qua non" necessary for the production of intrinsic factor by the oxyntic cells then a possible logical theory presents itself. I f we cou ld conclusively and consistently demonstrate a potent pyloric extract it would remain (1) to determine how closely this is related to histamine, (2) to correlate the gastr ic secretion it produces with intrinsic factor secretion, and (3) if results warranted it to determine the therapeutic effect of the pyloroduodenal hormone in increasing intrinsic factor secretion in swine with a pernicious anemia syndrome produced by die tary deficiency.

A D D I T I O N A L DATA Granting, as all of us will, that pepsin only par t ly

inactivates intrinsic factor it immediately is apparent tha t the gastr ic function would be very uneconomical i f intrinsic factor were produced in peptic cells. I t would seem that either intrinsic factor is produced in an independent cell or in the mucous or oxyntic cells. Careful studies in animals and man have not as yet disclosed any cells or group of granules, the special


function of which it is to secrete antianemic principle. I have made such studies under supervision and I have carefully reviewed (15, 32) the histological work of others as well as special s taining methods without being able to shed any light on the exact locus of intrinsic factor formation. Surely the cells of the pyloric gland region have no dist inguishing granular charac- teristics. On the other hand, there are many corre- lations between intrinsic factor and acid secretions to st imulate the imaginat ion and to suggest investigations. These are the inact ivat ing proper ty of pepsin which is a secretion pr imar i ly of the fundus glands, the practically constant association of achylia gast r ica and pernicious anemia, the report of a possible association between polycythemia and duodenal ulcer, the absence of ulcer in pernicious anemia and the demonstrat ion that destruction of oxyntic cell t issue by p i tu i ta ry extracts, as noted by Dodds and his group, with the production of achylia and a macrocytie blood picture in rabbits, at least suggest that the oxyntic cell reacts in direct proportion to the amount of antianemic factor secretion and it is not a f a r cry to suspect that this same cell may have 2 functions, one an external secretion of hydrochloric acid, the other secretion, pr imar i ly internal, of antianemic principle.

The unusual characteris t ics of the oxyntic cells have been observed by authori ta t ive investigators of the histology of the cells of the gastr ic glands. For example, it is pointed out that each possesses a remarkable system of secretory canaliculi which dis- charges into the lumen of the gland. Might this possibly suggest internal secretion? Structural differ- ences corresponding to physiological changes are not easily made out. The parietal cells seem not to undergo any morphological changes in connection with the various stages of functional activity.

Evidence suggestive of linking the manufacture of gast r in with the "mucoid" cells of the glands of Brun- ner, as well as with the pyloric glands of the stomach has been advanced by Murray (33). Murray found tha t when tha t par t of the duodenum which contains Brunner ' s glands is used the secretion by the stomach is greater , more HC1 and pepsin being produced. When par ts tha t do not contain Brunner ' s glands are used the effect is insignificant in almost every case. Murray excluded the effect of his tamine in these experiments for his tamine given intravenously in cats causes practically no response. I t must be recalled that Brun- ner ' s glands are exactly those to which antianemic potency has been a t t r ibuted by Meulengracht. There- fore, since the st imulation of acid and pepsin secretions are brought about by a hormonal mechanism, it seems plausible to assume a s imilar mechanism for intrinsic factor or antianemic principle. Moreover, Aschner and Grossman (34) point out tha t extracts of the duodenal mucosa containing Brunner ' s glands injected intravenously cause secretion of pepsin and hydrochloric acid by the stomach, thus resembling antral glands in function. I t becomes clear tha t functionally and histologically the pylorus and duodenum are related.

Fur thermore , it is interest ing in this connection to recall the studies of Downs and Eddy (35) on the influence of secretin on the number of erythrocytes in the circulating blood of rabbits. They were able to demonstrate a s t imulat ing effect by secretin presumably upon bone marrow. They also observed tha t the subcutaneous adminis t ra t ion of secretin to anemic

animals produced a much more rapid improvement than could be obtained by dietary ad jus tment alone. These experiments deserve fu r the r study.

In his original researches Castle pointed out that the intrinsic factor is not present in the duodenal cQn- tents f rom which gastr ic juice had been excluded. I f duodenal substance has antianemic potency and if duodenal contents do not have such potency then either the antianemic substance is secreted internally or the duodenal cells secrete a secretin-like mater ial which when absorbed stimulates secretion of antianemie principle in the gastr ic contents.

At this point it should be stressed that the absence of pernicious anemia a f t e r gast rectomy is due to the fact that all oxyntic tissue is not removed f rom the stomach (partial gastrectomy) or even when it is, which is rare, aber rant oxyntic t issue is still st imulated to secrete by the pyloroduodenal hormone. More- over, complete removal of the pylorus still leaves the duodenum which apparent ly has s imilar propert ies so fa r as the secretions under discussion are concerned.

CONCLUSION I t becomes evident f rom the preceding mater ial that

the problem of "gas t r in" remains a disputed one as we have already indicated. I t cannot be denied, however, that the glands of Brunner and the pyloric glands have similar functions with respect to hematopoiesis. The cells of these regions have different functions f rom those of the fundus according to most authori- ties. If, therefore, antianemic potency is proved to be present in the fundus glands then it would seem likely that the pyloric gland region with its antianemic potency demands a different e x p l a n a t i o n of its mechanism of action than the replacement of actual antianemic material . That different mechanism suggests i tself; namely, a gastr ic secretin analagous to pancreatic secretin.

I t is for these reasons tha t we have had the courage to hypothecate the p r e s e n c e of a pyloroduodenal hormone which activates oxyntic cell secretion of intrinsic factor. A disturbance in this mechanism would result in a t rue macrocytic anemia, that is, one in which the antianemic principle is absent either as a result of loss of the act ivat ing pyloroduodenal hormone or as the result of non-functioning oxyntic cells (including aberrant t issues). However, there is another large group of conditions in which a macrocytic anemia may occur; these are die tary deficiencies; in other words, purely the result of an absence of extrinsic factor. The lat ter group are not true pernicious anemia since the intrinsic factor mechanism is still present but is interfered with by a debility due to dietary lack. Others concur in this explanation. Such macrocytic anemias, i f not of too long standing, re- spond quickly to the adminis trat ion of the substance responsible for the dietary lack; the t rue pernicious anemia may be an end-result of extrinsic factor deficiency only because the anti-anemic principle secretion is interfered with by general glandular asthenia.

P E P S I N H Y P O T H E S I S Pepsin is secreted mainly if not entirely by the

fundus of the stomach. Pepsin may antagonize intrinsic factor potency of the fundus.

P E P S I N . CLINICAL AND E X P E R I M E N T A L DATA

Histological studies of gastr ic and duodenal cells


lead to the conclusion that the fundus may possibly elaborate the intrinsic fac tor but tha t its impotency in clinical tests may be due entirely to its pepsin con- teat. When physiological investigations are added to these it is interesting to note that the very cells to which are at tr ibuted those propert ies necessary to combat pernicious anemia are also at tr ibuted the possession of a hormone capable of st imulating hydrochloric acid and pepsin secretions. I f acid and pepsin secretion are brought about, at least in part, by this humoral mechanism, it follows that the antianemic principle or intrinsic factor may also possibly result f rom a similar mechanism.

As a result of Meulengracht 's work there is prepared in Denmark a commercial powder, known as Pylorin, which represents the pyloric-gland region. I t has about the same activity as Ventriculin. However, whole stomach (Ventriculin) should be less potent than pyloric-gland stomach unless the fundus has antianemic potency; otherwise the lack of potency in the fundus would diminish the potency of the whole stomach preparation. Moreover, if Greenspon's conception of the importance of pepsin is confirmed then it is that substance which inactivates fundus antipernicious anemia potency inasmuch as pepsin is so predominant in fundus tissue. Both Ventriculin and Pylorin have proteinaceous muscularis to act as an adsorbent of pepsin according to Greenspon, or as a source of extrinsic factor according to Castle.

We have reported elsewhere (36) our studies on the rSle of pepsin in pernicious anemia. Our materials, consisting of cardiac, fundic, p y l o r i c and whole stomach mucosae were depepsinized according to the method recommended. Interest ingly enough, as f a r back as 1922, Lim (21) had observed that the activity of the extracts which he used in producing gastr ic secretion depended in a measure on their mode of preparation. The order of potency of extracts of the mucous membrane of the stomach and small intestine he found to be of the following descending order: pyloric, cardiac, duodenal, fundic, jejunal and ileal but he believed he could change the order of potency by adopting different methods of extraction. Perhaps this helps to account for the confusing reports of Henning and Brugsch (37) (1931), Gutzeit and Hermann (38) (1931), Henning and Stieger (39) (1930) and later in 1934, Henning (40), regarding the comparative potency of cardia, fundus, pylorus and duodenum. Finally, however, the impression is gained that the pylorus is more potent than the other portions as regards its effect in combatt ing pernicious anemia. Meulen~racht (20) in 1935 rei terated this conclusion. Nevertheless, the mere fact that fundus mucosa was found to have some potency is important for it suggests tha t perhaps a f t e r all the presence of pepsin may interfere with the activity of fundus tissue. For example, Henning and Stieger (1930) reported that by adminis ter ing the mucous membrane of the body of the stomach and that of the an t rum pyloricum separately they found that both possessed the same blood regenera t ing power, and by proving that neither the one nor the other possessed a peptic ferment of any account in vitro, they believed they had confirmed the assumption that the effect of the powder was indeq pendent of peptic digestion of protein and was a p r imary and direct one on blood regeneration.

To test the hypothesis that pepsin is antagonistic to the antipernicious anemia factor in stomach we

t reated 3 patients with pernicious anemia with depepsinized whole stomach mucosa and depepsinized fundus and pylorus mucosa, obtained f rom the hog's stomach under conditions considered proper for pre- serving anti-pernicious anemia potency. We were unable to establish any effectiveness in these preparations alone or with the addition of extrinsic factor. One exception was noted in the use of depepsinized pyloric mucosa which manifested a minimal, though definite, antipernicious anemia activity when the extrinsic factor was added. However, we have reason to d o u b t t he possibility of completely depepsinizing fundus tissues by present methods and we suggest that the process of depepsinization may not always result in the same end-product. In one instance an active product may be obtained, in another an inactive one. Fur the r studies support this belief. Consequently, unless disproved, Greenspon's demonstration of the antagonism of pepsin t o w a r d t h e antipernicious anemia factor (Castle 's intrinsic factor) considered along with the known adsorptive capacity of protein and coupled with the histological knowledge of peptic cell predominance in the fundus of the stomach, all suggest a r61e for the fundus in pernicious anemia.

In view of the inactivity of our depepsinized products we questioned the status of intestinal per- meability. However, the response to products of known potency, though submaximal, was enough to rule out the factor of intestinal impermeability. The possibility seemed apparent tha t the process of depepsinization could have inactivated the intrinsic factor. There was no doubt as to the adequacy of our sources of extrinsic factor. We proceeded to t rea t a patient (41) with typical pernicious a n e m i a with simple desiccated stomach mucosa without any a t tempt being made to remove the pepsin or to go through the various ex- tractions as described by Greenspon. This preparat ion proved to be completely sat isfactory as a source of intr insic factor and we, therefore, assumed tha t the process of depepsinization destroyed ra ther than en- hanced the potency of these preparations. I t is im- por tant to keep clearly in mind that even if the process of depepsinization inactivated the antipernicious anemia potency of these preparat ions tha t result does not necessarily mean that the absence of pepsin per s~ decreases the potency. In other words, a distinction must be made between the physico-chemical changes occurring during depepsinization and the theoretic removal of pepsin without subjecting the mucosa to any changes which m i g h t influence the antipernicious anemia potency.

We decided to repeat the administrat ion of depepsinized preparat ions in increased dosage to two other patients in order to be sure that the maximum dosage of 40 grams each day, as already reported, was sufficient. Two patients were fed with 50 grams of depepsinized material each day. This would insure adequate dosage. Both patients were ideal for the ex- periment not only because their counts were low but also because they represented typical uncomplicated cases (no neurological signs or symptoms) of pernicious anemia. The first pat ient 's blood did not re- spond to adequate dosage of depepsinized pylorus mucosa administered orally along with the extrinsic factor. On the other hand, oral and intramuscular therapy of known potency produced a characterist ic response.

Curiously enough, the depepsinized fundus material


administered in the same manner was followed by a reticulocyte response of 7% on the 6th day after the onset of treatment. Whether this response, in the light of our previous data, was due to depepsinized fundus mucosa or to some extraneous factor or was spontaneous, it is difficult to determine with certainty. The expected maximum reticulocyte percentage, after desiccated stomach given orally, is about 40% for the level of this patient's blood. The response, therefore, is distinctly minimal. Nevertheless, is it not possible that depepsinized fundus material has antipernicious potency and that the reaction of this patient bears out our predictions that the process of depepsinization does not always result in the same end-product, that the overwhelming presence of pepsin in the fundus conceals its hematopoietic function and t h a t t h e process of depepsinization rather than the absence of pepsin may account for the inactivation of intrinsic factor? This is further supported by the observation that one patient treated with depepsinized pylorus mucosa plus extrinsic factor led us to conclude that pylorus mucosa had hematopoietic potency whereas a second patient treated with the same material prepared at another t ime did not react. On the other hand, a patient treated with depepsinized fundus mucosa led us to conclude that it was completely inactive whereas another patient reacted to the same material prepared at another time. Further studies are needed to bring these rather confusing results to a definite and perhaps significant reconciliation. I f fundus t issue has antipernicious anemia activity then this evidence supports our hypothesis concerning the action of a pyloroduodenal hormone. It is hardly possible that the increased dosage helps us explain our results since both pylorus and fundus were administered in equal doses in both studies.

Further studies of depepsinized stomach mucosa were made with pigeons but we have purposely excluded that data not only because it is controversial but because there is not sufficient t ime to present it adequately. I hope to do so on another occasion.

CONCLUSION The influence of pepsin on antipernicious anemia

activity of gastric t issue cannot be disregarded. An understanding of its exact r61e will require further study.

THE CONCEPTION SUMMARIZED Neutral red may be very useful as a specific test of

oxyntic cell function. At the same time it seems to detect a more minute degree of oxyntic cell viability than any other test at our disposal.

The study of neutral red excretion also suggests a pyloric control factor in oxyntic cell activity. Studies of pyloric extracts suggest the same conclusion. Since pylorus and duodenum are so intimately interrelated functionally and anatomically the hypothesis is offered that a pyloroduodena] hormone may regulate oxyntic cell activity. But pylorus and duodenum are also important in providing pernicious anemia-preventive factor. The likelihood that this activity of the pyloroduodenal region is entirely separate from the hormonal function appears to be remote. Therefore, the effort is made to demonstrate an interrelationship between all gastric secretions including the intrinsic factor.

Moreover, pepsin is antagonistic to anti-pernicious anemia activity. But pepsin is secreted by the fundus

of the stomach. If depepsinized fundus substance is potent in pernicious anemia then its mechanism of action must be different from depepsinized pylorus substance. Upon this demonstration the hypothesis of a pyloroduodenal hormone may also be substantiated.

REFERENCES 1. Glaessner, K. and Wittgeustein, H. : Ein Neuer Weg Zur Funk-

stionspriifung d e s G e s u n d e n und Kranken Magens. Klin. Wchn~chr., 2:1650, Aug. 27, 1923. Gastric Function Test. Archiv. Iiir Verdauungskr. , 34:303, Feb., 1925.

Glaessner, K. : Chromoskopie des Magens. Med. Klln. , 22:887-889, June 4, 1926.

2. Klein, E. : Gastric Secretion Af ter Part ial Gastrectomy. J . A. M. A., 89:1235, 1927. Gastric Secretion : V. Achlorhydrla Follow- ing Part ial Gastrectomy for Ulcer; Studies with Histamine and the Transplanted Gastric Pouch. Arch. Surg., 30:162, Jan. , 1935.

3. Henning, N. and Jiirgens, R.: Beziehungen der Farbstoffexkretion zur Sekretion und Morphologie des Kranken Magons. M~nchen. ~ned. Wchnschr., 77:1961, Nov. 14, 1930.

4. Henning, N. and Bach. E . : Determination of the Function of the Glands of the Fundus and of the Pylorus by the Clinical Method of Combined Gastric Function Test. Arch. Y. Verdc~uungskrankh, 49:155, 1931.

5. Morrison, S., Reeves, D. L. and Gardner, R. E . : The Elimination of Various Dyes from the Pavlov Pouch of Dogs. A m . Jour. Dig. Die. and Nutri t . , 3:551-557, Oct., 1936.

6. Morrlson, S., Gardner, R. E. and Reeves, D. L . : The Selective Elimination of Neutral Red Through the Gastric Mucosa. Jour. Lab. and Clln. Med., 21:822-828, May, 1936.

7. Kobayashl, K. : Experimental Studies on Absorption, Secretion and Excretion. On the Secretion and Absorption of Dyestuffs by the Stomach. I. On the Secretion of Dyestuffs into the Stomach. Acta Scholae Med., VIII , 465:468, 1926. II. Functional Test on the Stomach with Dyestuffs. Acta Scholae Med., VIII , 489, 1926.

8. Henning, N. : The Excretion of Dyestuffs Through the Gastric Mueosa. Microscopical Investigations on Living Animals. Arch. y. expsr. Path. u. Pharmek. , 165:191-207, Jan. , 1982.

9. Morrison, S.: The Importance of the Oxyntic Cell in Pernicious Anemia. Jour. Lab. and Clin, Med., 21:828-829, May, 1936.

10. Davidson, L. S. P. : Pernicious Anemia with Return of Hydro- chloHc Acid and Ferments Af ter Treatment . Brit . Meal. Jour., 1:182, Feb. 4, 1933.

11. Dodds, E. C., Noble, R. L. and Smith, E. R. : A Gastric Lesion Produced by an Extract of the Pi tui tary Gland. Lancet, 2:918, Oct. 27, 1934.

12. Dodds, E. C. and Noble, R. L. : Relation of the Pi tui tary Lobe of the Pi tui tary Gland to Anaemia and to Blood Formation. Nature , 135:788, May 11, 1936.

Dodds, E. C., Hills, G. M., Noble, R. L. and Williams, P. C. : The Posterior Lobe of the Pi tui tary Gland, Its Relationship to the Stomach and to the Blood Picture. Lancet, 1:1099, May 11, 1985.

13. Cutting, W. C., Dodds, E. C., Noble, R. L. and Williams, P. C.: Pi tui tary Control of Alimentary Blood Flow and Secretion. The Effect of Alterations in Blood Flow on Gastric Secretion. Pros. Roy. Sos. of London, 123:39, June, 1937.

14. Cutting, W. C., Dodds, E. C., Noble, R. L. and Williams, P. C. : Pi tui tary Control of Alimentary Blood Flow and Secretion. Gastric Secretion and Blood Flow in Hypoplysectromized Animals. Proe. Roy. Soe. of London, 123:49, June, 1937.

15. Morrison, S. : A Concept Offered in Explanation of Certain Cases of Pernicious Anemia. Intvrnatianal Clinics, 1:89, March, 1936.

16. Braun, B. : Mechanism of Therapeutic Action of Castle's Principle in Pernicious Anemia. Folia Haemat, 53:27, 1934.

17. Meulengracht, E. and Schiodt, E. : Pepsin and Rennin Activity in Preparations of Dried Stomach Substance from Cardiac, Fundic and Pyloric Portion, Respectively (Prel iminary Repor t l . Ugesk. f . ~aegsr., 96:187, 1934.

18. Greenspon, E. A. : The Nature of the Antipernicious Anemia Principle in Stomach. J . A. M. A., 106:266, Jan . 25, 1936.

19. Morrison, S. and Gardner, R. E. : A Pyloric Hormone in Pernicious Anemia. Med. Rev. of Rev., 42:339-871, Aug., 1936.

20. Meulengracht, E. : The Glands of the Stomach in Relation to Per- nicious Anemia ; with Special Reference to tbe Glands in the Pyloric Region. Pros. Roy. Soc. of Med. (Section on Medicine), 28:841, 1935.

21. Lira, R. K. S. : The Question of a Pyloric Hormone. Quwrterlll Jour. Ezp . Phys. , 13:79, 1922-23.

22. Ivy, A. C.: Gastro-Intestinal Principles. J . A. M. A., 106:506, 1935.

23. Castle, W. B. : The Etiology of Pernicious and Related Maerooytic Anemias. The Harvey Lectures, 30:37, 1934-35.

24. Goldhamer, S. M. : Relationship Between Gastric Juice Volume and Erythropoiesis in Patients with Untreated Pernicious Anemia. Proc. Sos. Ezp . Biol. and Med., 32:476, 1934.

25. Castle, W. B. and Minot, G. R. : Pathological Physiology and Clinical Description of the Anemias. Ozford Mcd. Publlvatlons, 1936.

26. Castle, W. B., Heath, C. W. and Strauss, M. B. : Observations on the Etiologic Relationship of Achylia Gastrica to Pernicious Anemia. Am. Jour. Med. Sci., 182:741, 1931.

27. Barnett , C. W.: The Significance of the Gastric Secretions in Pernicious Anemia. Am. Jour. Med. Sei., 182:170, 1931.

28. Strauss, M. B. and Castle, W. B. : Studies of Anemia in Pregnancy ; Etiologic Relationship of Gastric Secretory Defects and Dietary Deficiency to Hypochromic and Macrocytie (Pernicious) Anemias of Pregnancy and Trea tment of These Conditions. Am. Jour. Med. Sd . , 185:589, 1933.

29. Schiff, L. and Tabl, T. : Effects of Dessicated Hog's Stomach in Achlorhydria. Am. Jour. Dig. Dis. and Nutr i t . , 1:543, Oct., 1934.

30. Morris, R. S., Schiff, L., Foulger, J . H., Rich, M. L. and Sherman, J . E . : Observations on the Hematopoietie Hormone (Addisin) in Pernicious Anemia. Brit . Med. Jour., 2:1050, 1932.

81. Fouts, P. J., Helmer. O, M. and Zerfas, L. G.: Hematopolet ic Response to In t ramuscular Injections of Concentrated Human Gastric Juice. Brit . Med. Jour., 1:141, Jan. , 1934.

EDITORIALS 627

82. Morrison, S.: Newer Interpreta t ions and Conceptions of Gastric Mueosal Functions. I. Fur ther Advances in the Study of Gastric Achylia. II . Evidence Suggesting a Role for the Oxyntic Cell in Pernicious Anemia. (To be published).

33. Murray, M. M. : The Small Intestine and Gastric Secretion. With Special Reference to Brunner 's Glands. Jour. of Physiol., 69:48, 1930.

34. Aschner, O. W. and Grossman, S.: Gastritis and Duodenitis in Relation to the Ulcer Problem. S. G. O., 57:334, 1033.

85. Downs, A. W. and Eddy, N. B.: The Influence of Secretin on the Number of Erythrocytes in the Circulating Blood. Am. Jour. Physiol., 43:415, 1917. I I I . Secretin. I ts Mode of Action in Producing an Increase in the Number of Corpuscles in the Circulating Blood. Am. Jour. Physiol., 46:209, 1918. V. Secretin. Its Effect in Anemia, with a Note on the Supposed Similarity Between Secretin and Vitamin B. A m . Jour. Physiol., 58:296, 1921.

36. Morrison, S. : Studies in Pernicious Anemia. An Inquiry into the Role of Pepsin. (To be published) Annals of Int . Med.

37. Henning, N. and Brugsch, I-I. : Ueber die Verteilung des ~nti- anamischen Faktors in der Magenschleimhaut. Deutsche reed. Wchnschr., 57:757, May, 1931.

38. Gutzeit, K. and Her rman , J . : The Effect of Stomach Substance on Pernicious Anemia. (Natural Gastric Juice, Pylorie and Fundic Mucosa, Wall of the Small Intes t ine) . Miinchcn *ned. Wchnschr., 78:266, Feb., 1931.

39. Henning, N. and Stieger, G.: Die Bchandlung der Pernizi~sen An~imle mi t Magenschleimhaut Prapara ten . Klln. Wchnschr., 9:2145, Nov., 1930.

40. Heuning, N. : Ueber den Ursprung des Antiperniziosa-Prinzips. Mcd. Welt. , 8:1145, Aug., 1934.

41. Morrison, S.: A Comparison of the Antipernieious Anemia Potency of Depepsinized and Undepepsinized Gastric Mucosa. (To be published) Jour. Lab. and Clin. Med.

DISCUSSION DR. BORIS P. BABKIN (Montreal, Canada) : I listened

with great interest to your paper, Dr. Morrison. I don't think that I can discuss the anti-anemic factor because

the problems in which I am interested are rather far from this field. In some of your results, however, I am very interested. Thus, for instance, you have seen that the volume of the secretion depends greatly upon the activity of the parietal cells. We came to the same conclusion, which was based upon some different experiments. We believe that the whole fluid of the gastric juice is practically supplied by the parietal cells. The peptic, mucoid and mucous cells seem to secrete very little fluid. Again, in the case of a gastritis, you found in the gastric contents pepsin, but the amount of fluid was extremely small. In other words under these circumstances for some reason only the function of the parietal cells was para- lyzed.

With regard to the pyloric hormone, I was glad to hear that although you couldn't purify it completely from histamine, it seems you are on the way to get something which is not histamine. As I have previously stated, I could never agree that the pyloric hormone is histamine. Histamine undoubtedly plays a certain part in the regulation of the gastric secretion, namely, in the nervous phase, but probably not in the chemical phase. There is something else which acts as a hormone during the chemical phase. Possibly it is the substance which Dr. Komarov extracted from the pyloric mucosa using trichloracetic acid.

DR. SAMUEL M O R R I S O N (Baltimore, Maryland., closing the discussion) : I have no remarks to add except to thank Dr. Babkin for his discussion.

Editorials A NEW METHOD FOR DETECTING ULCERA-

TION OF THE DIGESTIVE TRACT

O NE of the most interesting suggestions recently made in the field of gastro-enterology is that of

Dr. E. E. Woldman of Cleveland, who got the idea that when a patient has an ulcerated area in the bowel, the normal high degree of impermeability of the mucosa to m a n y substances should be impaired. Reasoning along these lines I have long suspected that when a person who has always been able to eat some food, such as crab, with comfort, suddenly becomes highly allergic to it, it is because the formation of an ulcer has opened up a path through which much of the crab protein has gone unchanged through the liver into the blood. Somewhat against this theory, however, is the fact that during a study of the food-sensitiveness of 500 persons, I gained a strong impression that persons with ulcer and cancer of the stomach were particularly free from severe forms of food-sensitiveness.

At any rate, Woldman has devised a test in which a little phenolphthalein, dissolved first in alcohol and then in a little water, is drunk on an empty stomach. I f the mucosa of the digestive tract is ulcerated, some of the phenolphthalein promptly goes through into the blood and then into the urine, where it can easily be detected. In many tests Woldman has found that the new procedure agrees well with roentgenologic reports indicating the presence of breaks in the gastro-intestinal lining, and in some cases the method proved to be very helpful. I t may enable physicians to tell when a deformity in the duodenum means the presence of an open ulcer, and it may be useful in telling when an ulcer has healed and the patient can be freed from dietary restrictions.

If, as now appears, a negative test can rule out the presence of cancer in the digestive tract, we will have a most valuable tool added to our diagnostic kit.

Everyone will probably now start using the test, and within a few months we ought to know how useful and how t rus tworthy it is.

Walter C. Alvarez, Rochester.

SUGGESTIONS FOR A NEW SCIENCE

A NEW and promising field for research now awaits opening up and cultivation, and this is the a r t o f

so treating certain foods like beans and cabbage ' that they will lose much or all of their harmfulness to many sensitive men and women. That something can~ be done along this line is suggested by a number of facts :

As everyone knows, cooking grea t ly improves the digestibility of a number of foods, not only by break- ing up c~llulose partitions but also by altering irr i tant or somewhat poisonous substances. Thus apples, which when eaten raw cause discomfort in a large percentage of persons, when cooked appear usually to be harmless. During a study of food-sensitiveness made by Hinshaw and me, we met a number of intelligent persons who said that so fa r as they were concerned, the paring of certain foods, such as cucumbers, or the soaking of them in water or vinegar, or the cooking of them in a certain way, would render them harmless. Why shouldn't more research be done along this line, and might it not be possible to find some way of destroying or dissolving or altering chemically the substances in beans and other foods that cause them to be flatulent ?

Curiously, cooking brings out the harmful propert ies

a modern conception of gastric secretory functions

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