Battle Casualties in Korea, Studies of the Surgical Research Team, Volume I
Gastric and Salivary Secretion Following Injury*
Captain John M. Howard, MC, USAR
This study was part of a broad survey of the systemic response to injury carried out by the Surgical Research Team on the Eastern Front in Korea during 1952-1953. It had as its purpose to describe the secretory activity of the upper gastrointestinal tract following nonspecific injuries.
The response of the gastrointestinal tract is demonstrable, in part, by a decrease in motility and a decreased rate of absorption of water (deuteriumoxide).1 These changes are more pronounced when the gastrointestinal tract, per se, is directly injured but are demonstrable to a lesser extent when the injury is limited to the extremities.
Material and Methods
Ten battle casualties were studied on arrival at the forward surgical hospital. They were selected because their wounds represented various degrees of injury. Those having received analgesics were avoided as were those who had recently eaten. The lapse of time between injury and study varied between 2 and 18 hours.
A Levin tube was passed and the stomach was thoroughly emptied by syringe suction. The patient was turned from side to side and the foot and head were alternately elevated in an effort to empty the stomach completely. Repeatedly, study had to be discontinued when it was found that although the subject had been wounded 12 to 15 hours earlier and had not eaten since, his stomach was filled with food. Similarly, if bile was present in the stomach, study was discontinued.
The patient was instructed not to swallow saliva but to expectorate into a cup. He was studied during three consecutive periods, each 10 minutes in duration. In several of the studies the saliva was collected and measured during each 10-minute period.
Syringe suction, air inflation, and repeated changes in position were used in an effort to obtain a complete collection of the gastric secretion. The three gastric collections were measured and analyzed separately. Analysis consisted of a standard clinical-type gastric analysis by titration of the gastric juice with 0.1 normal sodium hydroxide to the end point of Topfer`s reagent and phenolphthalein. Results were expressed in clinical units or degrees of free and total acid.
2
*Previously published in Annals of Surgery 141: 342, 1955.
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The study was repeated on six of the patients on the second or third day after wounding.
Results
Four patients had minor wounds and were fully ambulatory at the time of admission. Each of these casualties had a normal gastric acidity (Fig.1). The average volume of each 10-minute period was 19 ml. (Table 1). One of these patients was studied again 2 days later and the volume and acidity of his gastric juice were almost identical with those of the original study.
Six patients had moderate to severe injuries. Each of these six patients had an achlorhydria. (Fig. 2). The study was repeated on five of the patients on the second or third day post-injury. On the latter date each patient had free acid in normal amounts (Fig. 3). The average volume collected per 10-minute period during the first test was 12 ml. and during the second test was 24 ml., an increase of 100 per cent.
Similarly, a decrease in salivation was noted immediately after severe injury but not following minor injury (Table l). The secretion of saliva paralled the secretion of hydrochloric acid by the stomach. Like the latter, the secretion of saliva returned toward normal after a lapse of 48 to 72 hours (Fig. 4).
Many patients, including two of these with major wounds, complained of moderate thirst for several hours after injury.
Discussion
Although this method of collecting samples was indirect and, therefore, probably incomplete, the consistency of the pattern leaves little doubt that following severe injury, there is a decrease in the secretion of saliva and a decrease in the secretion of hydrochloric acid by the stomach. There is reasonable evidence that the secretion of water by the stomach is also diminished but to a lesser extent.
These changes are probably mediated through the autonomic nervous system.
Control of Salivary Secretion
It has been repeatedly demonstrated that stimulation of the parasympathetic nerve (chorda tympani) to the salivary glands results in vasodilation in the glands and an increased secretion of saliva.3, 4, 5 Parasympathetic blocking agents, such as atropine, reduce the secretion of saliva; a fact which is routinely used in preanesthetic medication.
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Table 1. Gastric and Salivary Secretion in 10 Patients
Patient | Injury | Time Lapse Since Injury (hours) | Gastric Juice* | Saliva* | Time Lapse Between Tests (days) | Gastric Juices* | Saliva* | ||||
Volume (ml.) | Free Acid (degree) | Total Acid (degree) | Volume (ml.) | Volume (ml.) | Free Acid (degree) | Total Acid (degree) | Volume (ml.) | ||||
|
| Minor Injuries |
|
|
|
|
|
|
|
|
|
|
1 |
Minor soft tissue | 11 | 15 | 66 | 88 | 24 | --- | --- | --- | --- | --- |
2 |
Minor soft tissue | 18 | 29 | 22 | 54 | --- | --- | --- | --- | --- | --- |
3 |
Minor soft tissue | 2 | 12 | 51 | 78 | --- | --- | --- | --- | --- | --- |
4 |
Minor soft tissue | 4 | 19 | 9 | 29 | 14 | 2 | 18 | 9 | 27 | 22 |
|
| Major Injuries |
|
|
|
|
|
|
|
|
|
|
5 |
Multiple soft tissue wounds | 4 | 28 | 0 | 21 | 10 | 2 | 14 | 12 | 25 | 18 |
6 |
Multiple soft tissue wounds | 2 | 1 | 0 | 36 | 1 | 3 | 23 | 11 | 32 | 26 |
7 |
Wound of thigh, moderate shock | 6 | 11 | 0 | 7 | 6 | 3 | 46 | 26 | 43 | 29 |
8 |
Perforation of the lung, liver and gallbladder |
|
|
|
|
|
|
|
|
|
|
9 |
Perforation of the chest | 4 | 13 | 0 | --- | 5 | 3 | 18 | 9 | 27 | 22 |
10 |
Perforation of the colon | 5 | 10 | 0 | --- | --- | --- | --- | --- | --- | --- |
*Collection per 10-minute period; expressed as an average of three 10-minute periods.
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FIGURE1.
Demonstrating normal gastric secretion following minor injuries.
The volume of secretion is expressed in ml. per 10-minute period.
FIGURE2.
By comparison with Figure1, patients with more severe injuries
had no free hydrochloric acid in the gastric secretion (volume in ml.).
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FIGURE3.
Demonstrating the return of the secretion of hydrochloric acid by the stomach
after 48 to 72 hours. The secretion of acid may not have been fully restored
to normal by the time of the second study (volume in ml.).
Stimulation of the cervical sympathetic nerves or administration of epinephrine to animals has not resulted in major changes in salivation.6,7 This effect has not been adequately studied for Cannon,8in this regard, noted dry mouth of the person who is called upon to speak in public and surmised that it was due to sympathetic activity.
As was pointed out by Gregersen,9 salivary secretion is entirely under nervous, in contradistinction to hormonal, control. During active secretion induced by parasympathetic stimulation in the cat or dog, the blood flow per minute through the submaxillary gland was found to be 5or 6 ml. per gram of gland and the salivary flow to be 1 or 2 ml. per gram of gland.10 Thus the secretory cell could extract 33 per cent or more of the plasma-water flowing through. Occlusion of the carotid artery resulted in a prompt fall in secretion.11 In man, rapid withdrawal of 500 ml. of blood resulted in a sharp decrease in the salivary flow9(Fig. 5), a fact which has also been demonstrated by Gesell.11 The latter also demonstrated that blood flow through the gland could be reduced to approximately 15 per cent of normal by a rapid loss of 10 per cent of the blood volume. This occurred without
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FIGURE4.
Demonstrating the transient reduction in
secretion of saliva following major injuries.
a change in blood pressure and was presumably due to a compensatory vasoconstriction. These observations described by Gregersen and Gesell are quite comparable to the conditions and results noted in these battle casualties except, perhaps, that the changes were more prolonged in the soldiers. Such a reduction in blood flow through the salivary glands would seem comparable to that occurring in the renal circulation following injury.
The associated thirst noted in several of these soldiers could not be fully relieved by allowing them to hold water in their mouths. It was presumably therefore not due entirely to dryness of the buccal mucosa.
Gastric Function
The decrease in gastric motility following nonspecific trauma has been well recognized by clinicians. It was certainly confirmed by these casualties. Some soldiers under fire for several hours before injury, arrived at the hospital as late as 24 hours after their last meal and 12 to 15 hours after injury. Under such circumstances, the stomach was sometimes filled with food.
A similar observation was made by Cannon in his early experiments when he noted roentgenographically that following fear, gastric motility ceased.8He also made the following observations:
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FIGURE5.
Following hemorrhage, salivation decreased sharply. The blood pressure fell momentarily
from 125/90 to 105/75but then immediately returned to normal. A decrease in blood volume of
approximately 10 per cent resulted in a decrease of 80 per cent in the rate of the secretion of saliva(after Gregersen9).
A refined and sensitive woman, who had digestive difficulties, came with her husband to Boston to be examined. They went to a hotel for the night. The next morning the woman appeared at the consultant`s office an hour after having eaten a test meal. An examination of the gastric contents revealed no free acid, no digestion of the test breakfast, and the presence of a considerable amount of the supper of the previous evening. The explanation of this stagnation of the food in the stomach came from the family doctor, who reported that the husband had made the visit to the city an occasion for becoming uncontrollably drunk, and that he had by his escapade given his wife a night of turbulent anxiety. The second morning, after the woman had had a good rest, the gastric contents were again examined; the proper acidity was found, and the test breakfast was being normally digested and discharged.8
The neurogenic component of gastric secretion, as with salivary secretion, consists of a parasympathetic secretory stimulation. Vagal stimulation increases gastric secretion and vagotomy or atropine decreases gastric secretion of water and hydrochloric acid.
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The effect of epinephrine on gastric function has been studied in both animals and man. Elliott12 and others13 have confirmed the fact that following the administration of epinephrine, gastric motility is reduced. In dogs, epinephrine has been shown to depress gastric secretion14,15 and Moll and Flint16 demonstrated that in two patients, its administration was followed by a moderate decrease in acidity. Following a single injection, the free acid disappeared for an hour, only to return in an increased concentration. Bilateral splanchnic section in dogs was followed by hyperchlorhydria.
Hardy17 noted that during a period of 3 days following operative trauma the gastrointestinal drainage per Miller-Abbott tube was depressed. He noted that the maximal depression coincided with the maximal adrenal cortical response as indicated by depression of the concentration of circulating eosinophiles and the retention of water by the kidneys. He suggested that this relationship deserved further study.
Gray and his associates18 demonstrated that ACTH (100 mg. daily) or cortisone produced an increased secretion of hydrochloric acid but their observations were limited to patients who had been receiving the drugs for at least 7 days prior to the first study. Their observations, however, might suggest that the adrenal cortical response was not the mechanism of the gastric depression in the soldiers studied in this report. For the sake of future consideration, it should be noted that eosinophile counts were done prior to gastric analysis in four of the seriously injured soldiers and one of the men with minor trauma. In the first four, the eosinophile count and gastric acidity of each was approximately zero. In the latter patient, the eosinophile concentration was 37 cells/ml. and the gastric acidity was normal.
Posterior pituitary extracts have been shown to produce a reduction in gastric secretion19, 20, 21 as well as in urine formation. These observations require extension and correlation with other mechanisms.
The findings in the present report are probably due to vasoconstriction in the salivary glands, buccal mucosa, and stomach secondary to an increased activity of the sympathetic nervous system due to hemorrhage and excitement. Although these changes can be largely reproduced by the injection of epinephrine, they can also be reproduced by parasympathetic blockade by atropine. Itis conceivable that the response of the sympathetic nervous system is reinforced by a physiological blockade of the parasympathetic nervous system.
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Summary
Study of 10 battle casualties, beginning a few hours after injury, revealed that after major injury, but not after minor injury, a complex of decreased salivation, decreased gastric secretion of hydrochloric acid and perhaps water, decreased gastric motility, and occasionally thirst developed. These changes diminished or disappeared during the first 48 hours of the study.
References
1. Howard, J. M.: Studies of the Absorption and Equilibration of Water (Deuterium Oxide) from the Gastrointestinal Tract Following Injury. A Study of Battle Casualties in Korea. Surg., Gynec. & Obst. 100:69, 1955, (Chapter 2 of Volume II in this series.)
2. Department of the Army, Technical Manual 8-227.
3. Heidenhain, R.: Beitrage zur Lehre von der Speichelabsonderung. Stud. Physiol. Inst., Breslau.
4. Babkin, B. P., Gibbs, O. S., and Wolff, H. G.: Diehumoral Uebertragung der chorda tympani-Reisung. Arch. f. Exper. Path. u. Pharmakol. 168: 32, 1932.
5. Cattell, McK., Wolff, H. G., and Clark, D.: The Liberation of Adrenergic and Cholinergic Substances in the Submaxillary Gland. Am. J. Physiol. 109: 375, 1935.
6. Morgulis, S.: Fasting and Undernutrition. E. P. Dutton and Co., New York, 1932.
7. Best, C. H., and Taylor, N. B.: The Physiological Basis of Medical Practice (5th Ed.). Williams and Wilkins Co., Baltimore, 1950.
8. Cannon, W. B.: Bodily Changes in Pain, Hunger, Fear and Rage. D. Appleton-Century Co., New York, 1936.
9. Gregersen, M. I.: McLeod`s Physiology in Modern Medicine(9th Ed.), Philip Bard, Editor. C. V. Mosby Co., St. Louis, 1941.
10. Barcroft, J.: The Respiratory Function of the Blood. University Press, Cambridge, 1925.
11. Gesell, R.: Studies on Submaxillary Gland. IV. A Comparison of the Effects of Hemorrhage and of Tissue Abuse in Relation to Secondary Shock. Am. J. Physiol. 47: 468, 1918-19.
12. Elliott: J. Physiol. 32: 420, 1905. Quoted by Moll and Flint.
13. Brown and McSwiney: Quart. J. Exper. Physiol. 16:1, 1926. Quoted by Moll and Flint.
14. Rogers, J., Rahe, J. M., and Ablahadian, E.: The Stimulation and Inhibition of the Gastric Secretion which Follows the Subcutaneous Administration of Certain Organs Extract. Am. J. Physiol. 48: 79,1919.
15. Hess, W. R., and Gundlach, R.: Pflüger`s Arch.185:121, 1920. Quoted by Moll and Flint.
16. Moll, H., and Flint, E. R.: The Depressive Influence of the Sympathetic Nerves on Gastric Acidity. Brit. J. Surg. 16:283, l928.
17. Hardy, J. D.: The Adrenal Cortex and Post-operative Gastrointestinal Secretions. Surgery: 29: 517, 1951.
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18. Gray, S. J., Benson, J. A., Jr., Reifenstein, R. W., and Spiro, H. M.: Chronic Stress and Peptic Ulcer. I. Effect of Corticotropin(ACTH) and Cortisone on Gastric Secretion. J. A. M. A. 147: 1529,1951.
19. Hess, W. R., and Grundlach, R.: Der Einfluss von Hypophysenextraktauf die Magensaftsekretion. Arch. f. d. ges Physiol. 185: 137, 1920.
20. Dodds, E. C., and Noble, R. L.: The Action of Pituitary Extracts on Gastric Secretion. Proc. Royal Soc., London, S. B. 30:815, 1937.
21. Dodds, E. C., Noble, R. L., Scarff, R. W., and Williams, R. C.: Pituitary Control of Alimentary Blood Flow and Secretion Changes in the Stomach Produced by the Administration of Posterior Pituitary Extract. Proc. Royal Soc., London, S. B. 123: 22, 1937.
