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Special ArticlesFRACTIONAL TEST-MEALS ON STUDENTS

AWAITING EXAMINATION RESULTS

MICHAEL FLOYERM.B.Camb., M.R.C.P.

DENYS JENNINGSB.M. Oxfd, D.M.R.E. Camb.

From the Medical Unit of the London HospitalTHE association between disturbance of the guts and

emotional tension has been recognised since the begin-nings of literature. Older authors attributed emotionalinstability to weak guts. The pendulum has now swungover, and gastroduodenal and colonic disorders, bothfunctional and organic, are popularly ascribed either toexcessive mental strain or to a temperament badlyadjusted to normal strains.

Typical evidence for this change of view is the allegedfrequency of gut disorder following mental tension.A good example is Stewart and Winser’s (1942) paperon the increase in perforated peptic ulcer during air-raid periods. There are many other lines of evidence,such as the undue frequency of certain temperamentaltypes among ulcer patients (Davies and Wilson 1937),observations on the effect of emotion on quite a largenumber of patients with gastric nstulse, ranging from

Beaumont (1833) to Wolf and Wolff (1942), observationson experimental animals with fistulae or with transparentabdominal windows, X-ray observations on experimentalanimals and on normal and psychotic human subjects,and finally test-meal observations on mental patients andon subjects suffering from emotional stress or in whomstress is induced under hypnosis. Alvarez (1929) haswritten a very readable review, and Dunbar (1946)gives a modern bibliography.

Various mechanisms for the production of pepticulcers by emotion have been suggested. The idea thatinterruption of normal impulses from the brain, or theproduction of abnormal ones, may be responsible datesback to Kammerer (1818), who tried to explain theassociation between brain lesions and gastric ulcers.The theory of hypothalamic stimulation in its modernform was favoured by Stewart and Winser (1942) andseverely criticised by Jennings (1942). Selye (1943)reaffirmed the . claims ’of his " alarm " reaction ofischsemia followed by dilatation of capillaries and stasis.Cannon’s (1909) view of stasis and fermentation offood producing irritation, gastritis, and duodenitis is apossibility, and so is the idea of retrograde intestinalmovements associated with colonic irritability.As pointed out by Jennings (1942), the difficulty of

the theory of hypothalamic stimulation is that,.with rare

RESULTS OF FRACTIONAL TEST-MEALS IN SIXTEEN STUDENTS WHO PASSED AND FOUR WHO FAILED IN THEIREXAMINATIONS (17-20)

A.-PASSED A.-PASSED (continued)

F, free HC1; T, total acidity ; S, search ; B, bile.

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exceptions (Hoelzel 1942), many workers support theidea that stress causes reduced secretion and delayedemptying. Wolf and Wolff (1942), in their observationson

" Tom," and Wolff and Mittelman (1942), in furtherobservations on cases of gastritis, duodenitis, and pepticulcer, distinguish between anxiety associated with

hostility, resentment, or aggression, which causes hyper-function ofthe stomach,and anxietyassociatedwith depres-sion, whichcauses hypo-function.They notethe parallelbetween gas-tric secretionand salivarysecretion.The mouthdries up withfear, but

people spitwith rage.Hinds s

H o w e 1 1(1941) found,that test-meal curves

Graph showing mean free HCI of 16 students whopassed and 4 who failed in their examinations.Shaded area gives range of mean f2 S.E. in the 16who passed ; black line gives mean of 4 who failed.-vertical line gives time of announcement ofexamination results.

during air-raids were so irregular as to be useless, butunfor-tunately details were not published. Since no unselectedsamples could be found in the literature, it occurred toone of us to do fractional test-meals on students awaitingthe results of the M.B. examination, to give the resultsafter the first hour and to follow the curves for a furtherhour to see if passing or failing had any influence. Twentystudents volunteered, of whom sixteen passed and fourfailed. The technique used was to draw off as much ofthe fasting secretion as possible and then to give a gruelmeal. All the subjects either went without lunch or hadan early light carbohydrate meal. The tubes were passedbetween 4 and 4.30 P.M., samples were removed at20-mm. intervals, and the examination results wereannounced at 5.15 P.M.The accompanying table and figure show the exact

time relationship of the samples to the announcement ofthe results. There is no evidence of hypersecretion andno significant departure from expectation. It mightbe argued that the tension was not great enough. Wedo not believe this is valid, as during the first hour therewas a definite tense atmosphere in the room, and it wasdeliberately increased by sending messengers out to

inquire if all the results were yet ready, and by consultingsheets of foolscap. Possibly a larger sample might pickout the occasional abnormal case, but evaluation wouldthen be difficult.

SUMMARY

Fractional test-meal curves on twenty normal medicalstudents for an hour preceding and an hour following thedeclaration of examination results showed no abnormalitywhich could be ascribed to anxiety, depression, or

elation.REFERENCES

Alvarez, W. (1929) J. Amer. med. Ass. 92, 1231.Beaumont, W. (1833) Experiments and Observations on the Gastric

Juice, Plattsburgh.Cannon, W. B. (1909) Amer. J. med. Sci. 137, 480.Davies, D., Wilson, A. (1937) Lancet, ii, 1353.Dunbar, H. F. (1946) Emotions and Bodily Changes, New York.Hinds Howell, C. A. (1941) Brit. med. J. ii, 473.Hoelzel, F. (1942) Amer. J. digest. Dis. 9, 188.Jennings, D. (1942) Lancet, i, 365.Kammerer, H. (1818) Thesis, Stuttgart.Selye, H. (1943) Lancet, i, 252.Stewart, D. N., Winser, D. M. de R. (1942) Ibid, i, 259.Wolf, S., Wolff, H. G. (1942) Human Gastric Function, London.Wolff, H. G., Mittelman, B. (1942) Psychosomatic Med. 4 5.

In England NowA Running Commentary by Peripatetic CorrespondentsONE of your correspondents has urged a more careful

estimate of the results of surgery by following up thelater histories of patients. Then your leading articleof August 17 has drawn attention to the grisly state ofsome of the chronic sick, as discovered by a surveyundertaken by the Institute of Almoners, and amongthese " chronic sick " were men and women dying ofcarcinoma in varying degrees of misery. The surgeryof carcinoma has to some extent already been checked’by follow-up, and judging by the number of forms nowfilled in about these patients the follow-up will be moreaccurate and detailed and more widespread than hereto-fore. I have however an uneasy feeling that the form ofthe accepted carcinoma follow-up leads to surgery whichoften adds to the unhappiness of our patients insteadof alleviating it.The accepted criterion of success in the treatment of

carcinoma is the survival of the patient for an arbitraryperiod of years. Whether the patient is happy andcomfortable or in misery and pain is not recorded :his mere existence alive is regarded as proof of success.Because " survival " is an unpleasant word, hinting thatlife may be present but not necessarily very enjoyable,it is not used in this connexion ; the fallacious butcomforting word " cure " is used in its place. A surgeonwill blithely record in public the results of his treatmentof carcinomatous patients as a three, four, or five year" cure," lumping together the remainder as " recur-rences

" and therefore failures. Yet the end of a patientwith a recurrence may be a good deal pleasanter thanthat of a patient " cured." The comfort of the patienthas become obscured by the attempt to eradicate adisease, an attempt based on pathology and checkedby statistics, both of which ignore the happiness of thesufferer who dies in a different institution from thatwhich treats him at first. The introduction of bedsfor the chronic sick and dying in the same buildingwhere primary treatment is undertaken will go someway to humanising the statistics : till then it might bea good idea to record the results of the treatment ofcarcinoma as "alive," with or without recurrence,""comfortable or miserable."

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Almost certainly I qualify by residence and occupationto write as a practitioner in a Medically OvercrowdedArea (M.o.A.). There is in London ’one indubitableM.O.A., the one near Cavendish Square ; but in presentcontroversy it does not seem to count, and a substantialpark and famous wood separate mine from it. Mineis not what it was. There are many more people to thehouse and perhaps fewer doctors to the street than therewere, but I know of six G.P.S and as many dentists within200’yards of me-there may be more; houses are notthick on the ground so the proportion must be fairly high ;and besides we have been " spoken of," mentioned in thesame breath with such hotbeds as Bournemouth.And that brings me to the point. It is time, I think,

that someone in one of these strange places spoke up,for nowhere does experience more belie repute; and

repute so readily assumes the voice of authority. Thewhole country now knows our reputed habits. " Where-soever the carcass is there shall the vultures be gatheredtogether " puts them in a nutshell. Spying from afarthe congregation of the wealthy we buy ourselves intoa practice on borrowed thousands and have then nochoice but to get our money back by prostituting ourscience and art. Well may we yearn for a Charter ofLiberty to deliver us from this bondage ! Well may thecountry’s awakening social conscience move it to ariseand cleanse the Augean stable! And if Augean stableshave parasites, and parasites have socks, well may theybe compelled to pull them up and do a bit of honestwork elsewhere !

So much for repute. Now for experience. Twenty’five years ago your present peripatetic-no, the thirdperson is impossible. Once upon a time I, being young,eager, married and offspringing, but slightly mellowed byover four years of war, looked about for somewhere tolive. We had sampled the M.O.A. as a living-place and