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OPPOSITE ACTIONS OF THYROID AND ADRENAL HORMONES IN ALLERGIC HYPERSENSITIVITY
492 many films and help to relieve congestion greatly overworked X-ray departments of our hospitals. This would save not only money but also the chest physicians’ time.
would in the
save
REFERENCES
Hall, A. S. (1942) Lancet, i, 161. Tattersall, W. H. (1948) Ibid, ii, 974.
OPPOSITE ACTIONS OF THYROID AND ADRENAL HORMONES IN ALLERGIC HYPERSENSITIVITY D. A. LONG
A. A. MILES
M.D. Lond. M.A. Camb., F.R.C.P. From the National Institute for Medical Research, London AMONG the explanations of the characteristic tissue
reactions in rheumatoid arthritis, that of a chronic allergic hypersensitivity has received a good deal of attention (see, for example, Urbach and Gottlieb 1946). The striking modification of these reactions by the administration of adrenocorticotropic hormone (A.C.T.H.) or ’Cortisone’ (Hench et al. 1949) is consistent with this explanation, because the reactions ofanimals artificially hypersensitised to injection of the exciting allergen have also been modified substantially by increase or decrease of the adrenal hormones. Thus, adrenalectomy in
guineapigs (Kepinov 1922a) and rats (Flashman 1926) increases sensitivity to anaphylactic shock, whereas adrenocortical extracts temporarily diminish it in guineapigs (Wolfram and Zwemer 1935) and dogs (Dragstedt et al. 1937). Moreover, A.C.T.H. diminishes sensitivity in a variety of established allergic diseases (Bordley et al. 1949). This enhancement of hypersensitivity by deprivation, and its decrease by the giving, of adrenocortical hormones is matched, in the opposite sense, by the effect of thyroid secretions. Both tuberculin and anaphylactic hypersensitivity are recorded as decreased in thyroidectomised animals by Kepinov (1922b) and Kepinov and Metalnikov (1922) ; and according to Eickhoff (1939), neither allergic nor anaphylactic hypersensitivity can be induced in thyroidectomised guineapigs, but both develop in these animals when thyroid is given. "
EARLIER WORK
The idea of a balanced opposition between thyroid and adrenocortical hormones in the normal animal is of course not new. As early as 1917, Herring demonstrated, in
experimental hyperthyroidism, compensatory hypertrophy-and presumably hyperactivity-of the adrenal cortex, and many subsequent observers have confirmed this effect (e.g., Squier and Grabfield 1922, Gohar 1933, Gerlei 1938). In rats, atrophy of the adrenal cortex follows
of thyroid activity by thiouracil Baumann 1945, see also Zarrow and Money
suppression
(Marine and 1949).
days and then rested them for ten days, there was increased resistance to potassium chloride associated with the compensatory hypertrophy of the adrenal cortex. Again, whereas excess of thyroxine for a short period is followed by a drop in the cholesterol content of the adrenals, long-lasting excess induces hypertrophy of the gland and an absolute increase in the cholesterol content (Abelin 1944). Clearly, any antagonism between the two glands must be interpreted in terms of an immediate opposition of available hormones, and of the stimulus one hormone may give to compensatory production or overproduction of the other. FEATURES OF INVESTIGATION
The relation of the allergic state to the thyroidadrenal system is still obscure, partly because of the piecemeal evidence, and partly because the adrenal hormones hitherto used in this kind of work have been ill defined. With cortisone available in a purified state, we re-examined this relation in the hope of widening the investigation of problems which up till now have been tackled in terms of the adrenocortical hormones alone. From the preliminary work we record in this paper, three noteworthy features emerge : (1) the opposite nature of thyroxine and cortisone effects in allergy ; (2) the swing of allergic reactivity in the opposite direction two weeks after administration of either of the two hormones has ceased ; and (3) the use of the tuberculin-sensitive guineapig as a test object for the assay of substances with a cortisone-like effect. EFFECT OF THYROXINE AND PROPYLTHIOURACIL ON SENSITISATION TO TUBERCULIN
In our first tests with thyroxine (experiment 1), we relied upon twice-weekly intradermal injections of 2000 international units (i.u.) of tuberculin to induce
hypersensitivity. Each injection was made into a different site in the skin of healthy albino guineapigs weighing about 400 g. ; and twenty-four hours later the diameter of the reaction to that injection, was measured. Three groups of twenty animals were used (fig. 1) ; those in group i were given 0-2 mg. sodium week, and those in mouth three times a week ; group ill was the control. On the 10th day of treatment the tuberculin injections were started.
thyroxine subcutaneously three times group 11, 25 mg. propylthiouracil by
a
Sensitivity increased slowly in groups II and III, rapidly in the thyrotoxic animals (group I). On the 28th day, after 18 days’ sensitisation, half the animals in groups II and III were given thyroxine ; and, while in the remainder hypersensitivity did not increase materially, in these it increased very rapidly. The same increase occurred in ten animals of group I that continued to receive thyroxine ; but in ten taken off thyroxine after 28 days, hypersensitivity declined to that of the untreated
Among the further evidence of a thyroid-adrenal balance is the positive nitrogen balance maintained in adrenalectomised dogs by the simultaneous administration of cortin and thyroxine (Koelsche and Kendall 1935) ; the prolongation of life in adrenalectomised cats by thyroidectomy (Zwemer 1927) ; the inhibition of increased metabolism in acute experimental thyrotoxicosis byCortidyn ’ (Oehme 1936) ; the increased resistance of rats to potassium chloride poisoning induced by cortical extract, and its annulment by thyroid extract (Lowenstein and Zwemer 1943) ; and the stimulation of thyroid activity and hyperplasia by moderate injury to the adrenal cortex (Scott 1922). These effects are mainly acute. With prolonged modification of the thyroid secretion, the opposition of the adrenals has other consequences. For example, when Lowenstein and Zwemer gave their rats thyroid for ten
)—Effect of thyroxine and propylthiouracil on the course of sensitisation of guineapigs to tuberculin, measured by the diameter of 24-hour reactions to 2000 l.U. tuberculin injected intradermally twice weekly from the 10th day (expt 1). 1, thyroxine. 11, propylthiouracil. 111, controls. On the 28th day thyroxine was stopped in half the animals in 1, and was given to half the animals in 11 and III. Cross-hatching indicates a diffuse erythema of the animal’s skin. death of two animals. f
Fig.
,
493 animals in group III. The thyrotoxicosis was not severe ; its degree is evident from the variation in body-weight of the animals (fig. 2). It was in fact regulated so as to keep the weights of the animals approximately stationary -that is, if our hypothesis is correct, in a state of approxiTwo mate balance of thyroid and adrenal hormones. .animals in group i died after 42 days’ thyroxine, with haemorrhages in the adrenal cortex. In all the thyroxine-treated animals, the tuberculin reaction at about the 30th day was intense, with a flare-up at the sites of previous tuberculin injections and a diffuse erythema of the skin (see fig. 1). The hypersensitive reactions of the animals treated with propylthiouracil did not differ materially from those of untreated animals ; and in both groups the later treatment with thyroxine had the same effect. According to our other results (see below) we might expect a diminution of hypersensitivity by adrenal hormones becoming dominant as a result of depressed thyroid activity. Possibly the appropriate adjustment of the adrenal-thyroid balance during propylthiouracil treatment is more rapid than that during thyroxine intoxication, though on this we have no direct evidence. But the enhancement of hypersensitivity by thyroxine was
3. We had, e with these develanimals, oped a method for measuring changes in allergy with some preciMeasuresion. ment
of hypersensitivity is notoridifficult ; ously only very roughly
quantitative statements
are
usually possible. Tuberculosis may be measured Mantoux intradermal test, but the end-point thus achieved is
allergy crudely by the
relatively A better
proved
coarse.
measure
to
Fig. 3-Dose-responses
to 20, 80, and 320 LU. tuberculin in sensitive guineapigs. A, control ;; B, treated with thyroxine ; C, control 14 days later ; D, B 14 days later, having had no thyroxine since test B. (Table H, expt 2.)
be
(which we later found had been made possible by the discovery that the diameter of the 24-hour skin
by Wadley [1949]) lesion produced by a constant volume of tuberculin solution was directly proportional to the logarithm of the concentration of tuberculin. (A similar relation holds for diphtheria toxin [Miles 1949].) Method of Estimating Hypersensitivity.-In fig. 3 the lesion-diameters at 24 hours in four groups of infected guineapigs are plotted against the log dose of tuberculin, which was injected in 0-2 ml. volumes in doses of 20, 80, and 320 i.u. into the dorsolateral skin of the depilated animals. For each group the mean responses to the doses fall approximately on a straight line. All our tests were designed to yield data susceptible to the standard methods of regression analysis (Fisher 1947) ; and by these it was possible to prove that in each comparative test the dose-response lines were substantially straight and parallel to one another, but differed significantly in position. One such analysis is recorded in table i; the probability (p) that differences between responses to the three doses of tuberculin (b) and between responses by each group of animals as a whole (a), and that the two-dose response lines are not linear (c), is in all cases less than 1 in 100. In fig. 3, parallel regression-lines are fitted to A and B, and to C and D, which represent pairs of tests on thyroxine-treated animals (table 11, expt 2). Thus the horizontal distance between A and B is 0-39, which is the log ratio of the doses of tuberculin required to elicit a lesion of given diameter in the guineapigs of the two That is, group B animals require antilog groups. 0-39=2-5 times as little tuberculin as group A animals to give a reaction of, say, 20 mm. diameter, and are therefore 2-5 times more hypersensitive. Similarly group C is antilog 0-435=2-7 times less sensitive than group D. This method permits a precise numerical estimate of hypersensitivity and will, we hope, prove useful in the investigation both of allergy and of substances that modify allergy. The linear relation of log-dose with mean
ments as
in
of the guineapigs in expt 1. Groups and treatTreatment of half the animals in each group
changed at
the 28th
day.
- J=ig.
2-Mean
weights fig. I.
indubitable ; and it disappeared about
10 days after the thyroxine injections ceased. Thyroxine does not appear to have affected the rate of sensitisation, because after 10 days of the drug the animals in groups II and III reacted as violently to tuberculin as those in group I that had had thyroxine during the whole period of sensitisation. EFFECT OF THYROXINE, A.C.T.H., AND CORTISONE ON HYPERSENSITIVITY OF B.C.G.-INFECTED ANIMALS
B.C.G.-infected Guineapigs as Test Animals.-The rest of our tests were made with B.c.G.-infected guineapigs. Albino guineapigs, weighing 350-400 g., were given 2-5 mg. wet weight of B.C.G. into the right adductor muscles of the thigh and were submitted to tuberculin skin-tests some 30-48 days after this injection. They were housed under standard conditions and given Bruce and Parkes’s (1947) pellet diet and unlimited cabbage. We chose the tuberculin-sensitive guineapigs for three reasons :
1. Tuberculin sensitivity exemplifies the so-called " bacterial - allergy," as distinct from the anaphylactic or " Arthus hypersensitivity ; and we feel that if allergy in fact predominates in clinical syndromes which, like rheumatoid arthritis, yield to treatment with cortisone, it is likely to be bacterial "
"
"
"
in type. 2. The allergy is induced by infection with- living B.c.G., and, like natural allergy, is a progressive state, at least during the period in which we made the tests.
‘
TABLE I-ANALYSIS OF VARIANCE: MENT RECORDED IN FIG.
DATA FROM THE EXPERI-
3,
A AND B
494 OF HYPERSENSITIVITY ESTIMATIONS B.C.G.-INFECTED GUINEAPIGS
TABLE
II-SYNOPSIS
IN
In experiment 4 three daily subcutaneous doses of mg. cortisone decreased hypersensitivity fourfold, when tuberculin was given 4 hours after the last injection. In experiments 3 and 4 the effect was later reversed. Fourteen days after a single dose of A.C.T.H. the animals were 3-4 times as sensitive as the controls ; and fourteen days after three doses of cortisone hypersensitivity was nearly 9 times that in the controls. 1
DISCUSSION
Days refer to duration of 0-2 mg. thrice weekly; subcutaneously.
B.C.G. infection. Doses: thyroxine A.C.T.H. 0-6 mg., cortisone 1 mg. daily, all
lesion-diameter holds good for a number of substances besides diphtheria toxin and tuberculin ; we have in this laboratory demonstrated its validity for scarlet-fever toxin, Clostridiam welchii oc-toxin, histamine, and some histamine-liberating substances.
Results.-Table 11 summarises three experiments. The small number of animals in experiments 3 and 4 was dictated by the need for economy in A.C.T.H. and cortisone. However, the response of the guineapigs in each group was surprisingly consistent ; and even with the few animals used, analysis showed clearly that the ratio of
hypersensitivities The
statistically significant (p=0’05).
peptide prepared by Dr. C. J. O. R. test-rats 1 tig. produced an approximately
A.C.T.H. was a
Morris, in whose
30%
was
decrease in adrenal ascorbic acid.
The cortisone
was
part of a batch sent to Sir Henry Dale at the National Institute for Medical Research
by
E. C. Kendall in 1942.
In experiment 2, 12 days’ treatment with thyroxine increased hypersensitivity 2-5-fold, compared with con-
trols.
After
further 14
days, during which no more thyroxine given, hypersensitivity declined until it was only 1:2-7 that of the controls. In experiment 3 a single subcutaneous dose of A.C.T.H. decreased hypersensitivity 3’6-fold. Two and a half a
was
hours was chosen as the interval between A.C.T.H. and the tuberculin injection, because after this interval the effect of A.c.T.H. on adrenal ascorbic acid and cholesterol,
and, according to Sayers et al. (1944), cortical hormone, begins to mature.
Fig.
4-Effect of
on
the
output of
prolonged administration of thyroxine cholesterol.
The most striking results are : (1) the opposite effect of thyroxine on the one hand, and ofcortisone and A.C.T.H. on the other ; and (2) diminution of the effect some days after the administration of the hormone has ceased, and furthermore a swing in the opposite direction. With cortisone at least, this parallels the exacerbation of symptoms in patients with rheumatoid arthritis when the drug is withdrawn (Hench et al. 1949).
The overswing can be explained in terms of the opposition of thyroid and adrenal cortex. Such an explanation must be largely speculative ; but, quite apart from their opposite effects on hypersensitivity when tested in different groups of animals, we have some evidence that the thyroid and adrenocortical hormones opposed each other in the same animal. Thus animals given thyroxine throughout experiment 1 had enlarged adrenals, with pronounced cortical hypertrophy. Fig. 4 shows the maximum transverse sections of the adrenals from these animals, compared with those from the control group. The extreme sizes in the picture are the biggest and smallest found in each group, and the inner four sections represent intermediate sizes, which in each group were evenly distributed between the extremes. There was evidently compensatory hypertrophy of the adrenal cortex, and histologically the thyroids were in the resting stage. In experiment 2, therefore, it is not unreasonable to postulate an excessive adrenocortical activity for some days after the end of thyroxine
injections. With regard
to the overswing in the other direction, after stimulation of the coitx by A.C.T.H. or after an excessive dose of cortisone, an overcompensatory response of the thyroid, becoming manifest in its effect on allergy two weeks later, is clearly possible. Direct evidence of the opposition of the two glands, the nature of the adrenocortical hormones immediately or mediately responsible for modification of the allergic
the adrenal cortex of guineapigs. Maximum Above : controls. Below : thyroxine.
on
transverse
sections stained for
495
effects, and the time relations of the " overswing " in sensitivity remain to be demonstrated. Nevertheless,
there investigation
is a strong a priori case for extending the of adrenocortical effects on pathological the thyroid gland. It is unlikely to include processes that these effects can be described completely in terms of an adrenal-thyroid system, but the thyroid may prove to have a greater direct influence than has hitherto been suspected. Finally, it is evident from our results with animals infected with B.C.G. (a microbe of low virulence for the guineapig) that a pathological state developing as a result of the infection can be definitely, readily, and reversibly modified by simple changes in the balance of hormones. In rheumatoid arthritis Hench and his colleagues find it increasingly difficult to harmonize the microbic theory of the origin of rheumatoid arthritis with the phenomenon of relief by jaundice or pregnancy." Though we would support any attempt to eliminate all unnecessary hypotheses about rheumatoid arthritis, we feel, as a result of our investigations, that there is nothing contradictory in the hypothesis of certain consequences of infection (some of them perhaps allergic in nature) being modified in pregnancy or jaundice by accompanying biochemical changes-some of them perhaps hormonal in origin. we
"
SUMMARY
Past experimental work on the relation of the thyroid and adrenal cortex suggests that their hormones are opposed to each other. Allergic and anaphylactic hypersensitivity are among the physiological and pathological processes influenced in this way. Thyroxine appears to increase, and the adrenocortical hormones to decrease,
hypersensitivity. Using hypersensitivity to tuberculin in guineapigs as an example of bacterial " allergy, we devised a quantitative measure of allergy and have shown that : "
1. Moderate thyrotoxicos:L of two weeks’ duration increases hypersensitivity, whereas either three daily injections of cortisone or one injection of A.c.T.H. diminishes it ; moderate doses of propylthiouracil did not affect it. 2. Fourteen days after stopping the thyroxine injections’ there was a swing of the thyroxine effect in the opposite direction, and the animals were less hypersensitive than the ’
controls. 3. Fourteen or
PROCAINE PENICILLIN WITH ALUMINIUM
feel
the animals
after the treatment with either cortisone also a swing in the opposite direction. being more hypersensitive than the controls.
days
A.C.T.H., there now
was
In the thyroxine-treated animals there was adrenocortical hypertrophy, which may account for the " overswing " in allergy after fourteen days without thyroxine. The overswing " in the A.C.T.H. and cortisone-treated animals may be due to an analogous overcompensation in thyroid activity. "
We are indebted to Mr. C. J. O. R. Morris, PH.D., for the A.C.T.H., to Mrs. R. Pitt-Rivers for the thyroxine used, to Dr. Knud Tolderlund, of the State Serum Institute, Copenhagen, for the B.c.G., and to Dr. W. L. M. Perry for the statistical analyses. REFERENCES
MONOSTEARATE EFFECTS OF A SINGLE LARGE DOSE IN BED AND AMBULANT PATIENTS
J. H. PEACOCK M.B. Birm., F.R.C.S. SURGICAL REGISTRAR
PATHOLOGIST
UNIVERSITY OF BRISTOL AND UNITED BRISTOL HOSPITALS
OF the slow-release penicillin preparations recently introduced procaine penicillin in oil with 2% aluminium monostearate has proved the most effective in delaying absorption of the injected penicillin. Since its introduction by Buckwalter and Dickison (1948) several workers have compared its properties with those of soluble penicillin in oil or wax and procaine penicillin in oil or water (Robinson et al. 1948, Thomas et al. 1948, Floyd 1949, Young et al. 1949). Most of the work reported so far has been aimed at obtaining therapeutic blood-penicillin levels lasting for 24-48 hours ; and it is clear that a single intramuscular injection of 300,000 units of the aluminium-stearate preparation will achieve this object.
Kitchen et al. (1949) showed that larger doses (1,200,000 and 2,400,000 units) maintained a blood-penicillin level of 0-03 unit per ml., on the average, for about 7 days. Young et al. (1949) found that in eight of their patients a dose of 2,000,000 units gave continuous therapeutic blood-penicillin levels for 6-8 days. Neither of these groups of workers states whether their patients were A single-injection method which confined to bed. consistently gives a therapeutic effect of this duration would be particularly useful in treating outpatients with minor infective conditions since it would considerably reduce the number of injections given in the outpatient department, with obvious advantages for patients, nurses, and doctors. We have investigated the duration of therapeutic blood-penicillin levels in two main groups of patients after a single intramuscular injection of 2,000,000 units of procaine penicillin with aluminium stearate in arachis oil. It was realised that results in bed patients and ambulant patients might be different. Boger et al. (1948) and Emery et al. (1949) noted that after the injection of procaine penicillin (without aluminium stearate) the blood-penicillin levels tended to fall more rapidly in ambulant patients than in bed patients. For this reason we have compared results in these two groups. Among those included in the trial were 48 outpatients with boils, carbuncles, and minor sepsis of the hand, and in these the clinical results were noted. A’ statistical comparison of these cases with others treated in other ways was not, however, attempted. Among the surgical DR.
LONG,
DR. MILES:
REFERENCES
(continued)
Herring, P. T. (1917) Quart. J. exp. Physiol. ii, 47. Kepinov, L. (1922a) C.R. Soc. Biol. Paris, 87, 327. (1922b) Ibid, p. 494. Metalnikov, S. (1922) Ibid, p. 210. Koelsche, G. A., Kendall, E. C. (1935) Amer. J. Physiol. 113, 335. Lowenstein, B. E., Zwemer, R. L. (1943) Endocrinology, 33, 361. Marine, D., Baumann, E. J. (1945) Amer. J. Physiol. 144, 69. Miles, A. A. (1949) Brit. J. exp. Path. 30, 319. Oehme, C. (1936) Klin. Wschr. 15, 512. Sayers, G., Sayers, M. A., Lewis, H. L., Long, C. N. H. (1944) Proc. Soc. exp. Biol., N.Y. 55, 238. Scott, W. J. M. (1922) J. exp. Med. 36, 199. Squier, T. L., Grabfield, G. P. (1922) Endocrinology, 6, 85. Urbach, E., Gottlieb, P. M. (1946) Allergy. London. Wadley, F. M. (1949) Amer. Rev. Tuberc. 60, 131. Wolfram, J., Zwemer, R. L. (1935) J. exp. Med. 61, 9. Zarrow, M. X., Money, W. L. (1949) Endocrinology, 44, 345. Zwemer, R. L. (1927) Amer. J. Physiol. 79, 658. —
Abelin, I. (1944) Helv. chim. Acta, 27, 293. Bordley, J. E., Carey, R. A., Harvey, A. M., Howard, J. E., Kattus, A. A., Newman, E. V., Winkenwerder, W. L. (1949) Bull. Johns Hopk. Hosp. 85, 396. Bruce, H. M., Parkes, A. S. (1947) J. Hyg., Camb. 45, 70. Dragstedt, C. A., Mills, M. A., Mead, F. B. (1937) J. Pharmacol. 59, 359. Eickhoff, W. (1939) Virchows Arch. 303, 481. Fisher, R. A. (1947) Statistical Methods for Research Workers. Edinburgh. Flashman, D. M. (1926) J. infect. Dis. 38, 461. Gerlei, F. (1938) Endokrinologie, 19, 387. Gohar, H. A. F. (1933) J. Physiol. 80, 305. Hench. P. S., Kendall, E. C., Slocumb, C. H., Polley, H. F. (1949) Proc. Mayo Clin. 24, 181.
W. A. GILLESPIE M.R.C.P.I., D.P.H.
M.D. Dubl.,
—
would in the
save
REFERENCES
Hall, A. S. (1942) Lancet, i, 161. Tattersall, W. H. (1948) Ibid, ii, 974.
OPPOSITE ACTIONS OF THYROID AND ADRENAL HORMONES IN ALLERGIC HYPERSENSITIVITY D. A. LONG
A. A. MILES
M.D. Lond. M.A. Camb., F.R.C.P. From the National Institute for Medical Research, London AMONG the explanations of the characteristic tissue
reactions in rheumatoid arthritis, that of a chronic allergic hypersensitivity has received a good deal of attention (see, for example, Urbach and Gottlieb 1946). The striking modification of these reactions by the administration of adrenocorticotropic hormone (A.C.T.H.) or ’Cortisone’ (Hench et al. 1949) is consistent with this explanation, because the reactions ofanimals artificially hypersensitised to injection of the exciting allergen have also been modified substantially by increase or decrease of the adrenal hormones. Thus, adrenalectomy in
guineapigs (Kepinov 1922a) and rats (Flashman 1926) increases sensitivity to anaphylactic shock, whereas adrenocortical extracts temporarily diminish it in guineapigs (Wolfram and Zwemer 1935) and dogs (Dragstedt et al. 1937). Moreover, A.C.T.H. diminishes sensitivity in a variety of established allergic diseases (Bordley et al. 1949). This enhancement of hypersensitivity by deprivation, and its decrease by the giving, of adrenocortical hormones is matched, in the opposite sense, by the effect of thyroid secretions. Both tuberculin and anaphylactic hypersensitivity are recorded as decreased in thyroidectomised animals by Kepinov (1922b) and Kepinov and Metalnikov (1922) ; and according to Eickhoff (1939), neither allergic nor anaphylactic hypersensitivity can be induced in thyroidectomised guineapigs, but both develop in these animals when thyroid is given. "
EARLIER WORK
The idea of a balanced opposition between thyroid and adrenocortical hormones in the normal animal is of course not new. As early as 1917, Herring demonstrated, in
experimental hyperthyroidism, compensatory hypertrophy-and presumably hyperactivity-of the adrenal cortex, and many subsequent observers have confirmed this effect (e.g., Squier and Grabfield 1922, Gohar 1933, Gerlei 1938). In rats, atrophy of the adrenal cortex follows
of thyroid activity by thiouracil Baumann 1945, see also Zarrow and Money
suppression
(Marine and 1949).
days and then rested them for ten days, there was increased resistance to potassium chloride associated with the compensatory hypertrophy of the adrenal cortex. Again, whereas excess of thyroxine for a short period is followed by a drop in the cholesterol content of the adrenals, long-lasting excess induces hypertrophy of the gland and an absolute increase in the cholesterol content (Abelin 1944). Clearly, any antagonism between the two glands must be interpreted in terms of an immediate opposition of available hormones, and of the stimulus one hormone may give to compensatory production or overproduction of the other. FEATURES OF INVESTIGATION
The relation of the allergic state to the thyroidadrenal system is still obscure, partly because of the piecemeal evidence, and partly because the adrenal hormones hitherto used in this kind of work have been ill defined. With cortisone available in a purified state, we re-examined this relation in the hope of widening the investigation of problems which up till now have been tackled in terms of the adrenocortical hormones alone. From the preliminary work we record in this paper, three noteworthy features emerge : (1) the opposite nature of thyroxine and cortisone effects in allergy ; (2) the swing of allergic reactivity in the opposite direction two weeks after administration of either of the two hormones has ceased ; and (3) the use of the tuberculin-sensitive guineapig as a test object for the assay of substances with a cortisone-like effect. EFFECT OF THYROXINE AND PROPYLTHIOURACIL ON SENSITISATION TO TUBERCULIN
In our first tests with thyroxine (experiment 1), we relied upon twice-weekly intradermal injections of 2000 international units (i.u.) of tuberculin to induce
hypersensitivity. Each injection was made into a different site in the skin of healthy albino guineapigs weighing about 400 g. ; and twenty-four hours later the diameter of the reaction to that injection, was measured. Three groups of twenty animals were used (fig. 1) ; those in group i were given 0-2 mg. sodium week, and those in mouth three times a week ; group ill was the control. On the 10th day of treatment the tuberculin injections were started.
thyroxine subcutaneously three times group 11, 25 mg. propylthiouracil by
a
Sensitivity increased slowly in groups II and III, rapidly in the thyrotoxic animals (group I). On the 28th day, after 18 days’ sensitisation, half the animals in groups II and III were given thyroxine ; and, while in the remainder hypersensitivity did not increase materially, in these it increased very rapidly. The same increase occurred in ten animals of group I that continued to receive thyroxine ; but in ten taken off thyroxine after 28 days, hypersensitivity declined to that of the untreated
Among the further evidence of a thyroid-adrenal balance is the positive nitrogen balance maintained in adrenalectomised dogs by the simultaneous administration of cortin and thyroxine (Koelsche and Kendall 1935) ; the prolongation of life in adrenalectomised cats by thyroidectomy (Zwemer 1927) ; the inhibition of increased metabolism in acute experimental thyrotoxicosis byCortidyn ’ (Oehme 1936) ; the increased resistance of rats to potassium chloride poisoning induced by cortical extract, and its annulment by thyroid extract (Lowenstein and Zwemer 1943) ; and the stimulation of thyroid activity and hyperplasia by moderate injury to the adrenal cortex (Scott 1922). These effects are mainly acute. With prolonged modification of the thyroid secretion, the opposition of the adrenals has other consequences. For example, when Lowenstein and Zwemer gave their rats thyroid for ten
)—Effect of thyroxine and propylthiouracil on the course of sensitisation of guineapigs to tuberculin, measured by the diameter of 24-hour reactions to 2000 l.U. tuberculin injected intradermally twice weekly from the 10th day (expt 1). 1, thyroxine. 11, propylthiouracil. 111, controls. On the 28th day thyroxine was stopped in half the animals in 1, and was given to half the animals in 11 and III. Cross-hatching indicates a diffuse erythema of the animal’s skin. death of two animals. f
Fig.
,
493 animals in group III. The thyrotoxicosis was not severe ; its degree is evident from the variation in body-weight of the animals (fig. 2). It was in fact regulated so as to keep the weights of the animals approximately stationary -that is, if our hypothesis is correct, in a state of approxiTwo mate balance of thyroid and adrenal hormones. .animals in group i died after 42 days’ thyroxine, with haemorrhages in the adrenal cortex. In all the thyroxine-treated animals, the tuberculin reaction at about the 30th day was intense, with a flare-up at the sites of previous tuberculin injections and a diffuse erythema of the skin (see fig. 1). The hypersensitive reactions of the animals treated with propylthiouracil did not differ materially from those of untreated animals ; and in both groups the later treatment with thyroxine had the same effect. According to our other results (see below) we might expect a diminution of hypersensitivity by adrenal hormones becoming dominant as a result of depressed thyroid activity. Possibly the appropriate adjustment of the adrenal-thyroid balance during propylthiouracil treatment is more rapid than that during thyroxine intoxication, though on this we have no direct evidence. But the enhancement of hypersensitivity by thyroxine was
3. We had, e with these develanimals, oped a method for measuring changes in allergy with some preciMeasuresion. ment
of hypersensitivity is notoridifficult ; ously only very roughly
quantitative statements
are
usually possible. Tuberculosis may be measured Mantoux intradermal test, but the end-point thus achieved is
allergy crudely by the
relatively A better
proved
coarse.
measure
to
Fig. 3-Dose-responses
to 20, 80, and 320 LU. tuberculin in sensitive guineapigs. A, control ;; B, treated with thyroxine ; C, control 14 days later ; D, B 14 days later, having had no thyroxine since test B. (Table H, expt 2.)
be
(which we later found had been made possible by the discovery that the diameter of the 24-hour skin
by Wadley [1949]) lesion produced by a constant volume of tuberculin solution was directly proportional to the logarithm of the concentration of tuberculin. (A similar relation holds for diphtheria toxin [Miles 1949].) Method of Estimating Hypersensitivity.-In fig. 3 the lesion-diameters at 24 hours in four groups of infected guineapigs are plotted against the log dose of tuberculin, which was injected in 0-2 ml. volumes in doses of 20, 80, and 320 i.u. into the dorsolateral skin of the depilated animals. For each group the mean responses to the doses fall approximately on a straight line. All our tests were designed to yield data susceptible to the standard methods of regression analysis (Fisher 1947) ; and by these it was possible to prove that in each comparative test the dose-response lines were substantially straight and parallel to one another, but differed significantly in position. One such analysis is recorded in table i; the probability (p) that differences between responses to the three doses of tuberculin (b) and between responses by each group of animals as a whole (a), and that the two-dose response lines are not linear (c), is in all cases less than 1 in 100. In fig. 3, parallel regression-lines are fitted to A and B, and to C and D, which represent pairs of tests on thyroxine-treated animals (table 11, expt 2). Thus the horizontal distance between A and B is 0-39, which is the log ratio of the doses of tuberculin required to elicit a lesion of given diameter in the guineapigs of the two That is, group B animals require antilog groups. 0-39=2-5 times as little tuberculin as group A animals to give a reaction of, say, 20 mm. diameter, and are therefore 2-5 times more hypersensitive. Similarly group C is antilog 0-435=2-7 times less sensitive than group D. This method permits a precise numerical estimate of hypersensitivity and will, we hope, prove useful in the investigation both of allergy and of substances that modify allergy. The linear relation of log-dose with mean
ments as
in
of the guineapigs in expt 1. Groups and treatTreatment of half the animals in each group
changed at
the 28th
day.
- J=ig.
2-Mean
weights fig. I.
indubitable ; and it disappeared about
10 days after the thyroxine injections ceased. Thyroxine does not appear to have affected the rate of sensitisation, because after 10 days of the drug the animals in groups II and III reacted as violently to tuberculin as those in group I that had had thyroxine during the whole period of sensitisation. EFFECT OF THYROXINE, A.C.T.H., AND CORTISONE ON HYPERSENSITIVITY OF B.C.G.-INFECTED ANIMALS
B.C.G.-infected Guineapigs as Test Animals.-The rest of our tests were made with B.c.G.-infected guineapigs. Albino guineapigs, weighing 350-400 g., were given 2-5 mg. wet weight of B.C.G. into the right adductor muscles of the thigh and were submitted to tuberculin skin-tests some 30-48 days after this injection. They were housed under standard conditions and given Bruce and Parkes’s (1947) pellet diet and unlimited cabbage. We chose the tuberculin-sensitive guineapigs for three reasons :
1. Tuberculin sensitivity exemplifies the so-called " bacterial - allergy," as distinct from the anaphylactic or " Arthus hypersensitivity ; and we feel that if allergy in fact predominates in clinical syndromes which, like rheumatoid arthritis, yield to treatment with cortisone, it is likely to be bacterial "
"
"
"
in type. 2. The allergy is induced by infection with- living B.c.G., and, like natural allergy, is a progressive state, at least during the period in which we made the tests.
‘
TABLE I-ANALYSIS OF VARIANCE: MENT RECORDED IN FIG.
DATA FROM THE EXPERI-
3,
A AND B
494 OF HYPERSENSITIVITY ESTIMATIONS B.C.G.-INFECTED GUINEAPIGS
TABLE
II-SYNOPSIS
IN
In experiment 4 three daily subcutaneous doses of mg. cortisone decreased hypersensitivity fourfold, when tuberculin was given 4 hours after the last injection. In experiments 3 and 4 the effect was later reversed. Fourteen days after a single dose of A.C.T.H. the animals were 3-4 times as sensitive as the controls ; and fourteen days after three doses of cortisone hypersensitivity was nearly 9 times that in the controls. 1
DISCUSSION
Days refer to duration of 0-2 mg. thrice weekly; subcutaneously.
B.C.G. infection. Doses: thyroxine A.C.T.H. 0-6 mg., cortisone 1 mg. daily, all
lesion-diameter holds good for a number of substances besides diphtheria toxin and tuberculin ; we have in this laboratory demonstrated its validity for scarlet-fever toxin, Clostridiam welchii oc-toxin, histamine, and some histamine-liberating substances.
Results.-Table 11 summarises three experiments. The small number of animals in experiments 3 and 4 was dictated by the need for economy in A.C.T.H. and cortisone. However, the response of the guineapigs in each group was surprisingly consistent ; and even with the few animals used, analysis showed clearly that the ratio of
hypersensitivities The
statistically significant (p=0’05).
peptide prepared by Dr. C. J. O. R. test-rats 1 tig. produced an approximately
A.C.T.H. was a
Morris, in whose
30%
was
decrease in adrenal ascorbic acid.
The cortisone
was
part of a batch sent to Sir Henry Dale at the National Institute for Medical Research
by
E. C. Kendall in 1942.
In experiment 2, 12 days’ treatment with thyroxine increased hypersensitivity 2-5-fold, compared with con-
trols.
After
further 14
days, during which no more thyroxine given, hypersensitivity declined until it was only 1:2-7 that of the controls. In experiment 3 a single subcutaneous dose of A.C.T.H. decreased hypersensitivity 3’6-fold. Two and a half a
was
hours was chosen as the interval between A.C.T.H. and the tuberculin injection, because after this interval the effect of A.c.T.H. on adrenal ascorbic acid and cholesterol,
and, according to Sayers et al. (1944), cortical hormone, begins to mature.
Fig.
4-Effect of
on
the
output of
prolonged administration of thyroxine cholesterol.
The most striking results are : (1) the opposite effect of thyroxine on the one hand, and ofcortisone and A.C.T.H. on the other ; and (2) diminution of the effect some days after the administration of the hormone has ceased, and furthermore a swing in the opposite direction. With cortisone at least, this parallels the exacerbation of symptoms in patients with rheumatoid arthritis when the drug is withdrawn (Hench et al. 1949).
The overswing can be explained in terms of the opposition of thyroid and adrenal cortex. Such an explanation must be largely speculative ; but, quite apart from their opposite effects on hypersensitivity when tested in different groups of animals, we have some evidence that the thyroid and adrenocortical hormones opposed each other in the same animal. Thus animals given thyroxine throughout experiment 1 had enlarged adrenals, with pronounced cortical hypertrophy. Fig. 4 shows the maximum transverse sections of the adrenals from these animals, compared with those from the control group. The extreme sizes in the picture are the biggest and smallest found in each group, and the inner four sections represent intermediate sizes, which in each group were evenly distributed between the extremes. There was evidently compensatory hypertrophy of the adrenal cortex, and histologically the thyroids were in the resting stage. In experiment 2, therefore, it is not unreasonable to postulate an excessive adrenocortical activity for some days after the end of thyroxine
injections. With regard
to the overswing in the other direction, after stimulation of the coitx by A.C.T.H. or after an excessive dose of cortisone, an overcompensatory response of the thyroid, becoming manifest in its effect on allergy two weeks later, is clearly possible. Direct evidence of the opposition of the two glands, the nature of the adrenocortical hormones immediately or mediately responsible for modification of the allergic
the adrenal cortex of guineapigs. Maximum Above : controls. Below : thyroxine.
on
transverse
sections stained for
495
effects, and the time relations of the " overswing " in sensitivity remain to be demonstrated. Nevertheless,
there investigation
is a strong a priori case for extending the of adrenocortical effects on pathological the thyroid gland. It is unlikely to include processes that these effects can be described completely in terms of an adrenal-thyroid system, but the thyroid may prove to have a greater direct influence than has hitherto been suspected. Finally, it is evident from our results with animals infected with B.C.G. (a microbe of low virulence for the guineapig) that a pathological state developing as a result of the infection can be definitely, readily, and reversibly modified by simple changes in the balance of hormones. In rheumatoid arthritis Hench and his colleagues find it increasingly difficult to harmonize the microbic theory of the origin of rheumatoid arthritis with the phenomenon of relief by jaundice or pregnancy." Though we would support any attempt to eliminate all unnecessary hypotheses about rheumatoid arthritis, we feel, as a result of our investigations, that there is nothing contradictory in the hypothesis of certain consequences of infection (some of them perhaps allergic in nature) being modified in pregnancy or jaundice by accompanying biochemical changes-some of them perhaps hormonal in origin. we
"
SUMMARY
Past experimental work on the relation of the thyroid and adrenal cortex suggests that their hormones are opposed to each other. Allergic and anaphylactic hypersensitivity are among the physiological and pathological processes influenced in this way. Thyroxine appears to increase, and the adrenocortical hormones to decrease,
hypersensitivity. Using hypersensitivity to tuberculin in guineapigs as an example of bacterial " allergy, we devised a quantitative measure of allergy and have shown that : "
1. Moderate thyrotoxicos:L of two weeks’ duration increases hypersensitivity, whereas either three daily injections of cortisone or one injection of A.c.T.H. diminishes it ; moderate doses of propylthiouracil did not affect it. 2. Fourteen days after stopping the thyroxine injections’ there was a swing of the thyroxine effect in the opposite direction, and the animals were less hypersensitive than the ’
controls. 3. Fourteen or
PROCAINE PENICILLIN WITH ALUMINIUM
feel
the animals
after the treatment with either cortisone also a swing in the opposite direction. being more hypersensitive than the controls.
days
A.C.T.H., there now
was
In the thyroxine-treated animals there was adrenocortical hypertrophy, which may account for the " overswing " in allergy after fourteen days without thyroxine. The overswing " in the A.C.T.H. and cortisone-treated animals may be due to an analogous overcompensation in thyroid activity. "
We are indebted to Mr. C. J. O. R. Morris, PH.D., for the A.C.T.H., to Mrs. R. Pitt-Rivers for the thyroxine used, to Dr. Knud Tolderlund, of the State Serum Institute, Copenhagen, for the B.c.G., and to Dr. W. L. M. Perry for the statistical analyses. REFERENCES
MONOSTEARATE EFFECTS OF A SINGLE LARGE DOSE IN BED AND AMBULANT PATIENTS
J. H. PEACOCK M.B. Birm., F.R.C.S. SURGICAL REGISTRAR
PATHOLOGIST
UNIVERSITY OF BRISTOL AND UNITED BRISTOL HOSPITALS
OF the slow-release penicillin preparations recently introduced procaine penicillin in oil with 2% aluminium monostearate has proved the most effective in delaying absorption of the injected penicillin. Since its introduction by Buckwalter and Dickison (1948) several workers have compared its properties with those of soluble penicillin in oil or wax and procaine penicillin in oil or water (Robinson et al. 1948, Thomas et al. 1948, Floyd 1949, Young et al. 1949). Most of the work reported so far has been aimed at obtaining therapeutic blood-penicillin levels lasting for 24-48 hours ; and it is clear that a single intramuscular injection of 300,000 units of the aluminium-stearate preparation will achieve this object.
Kitchen et al. (1949) showed that larger doses (1,200,000 and 2,400,000 units) maintained a blood-penicillin level of 0-03 unit per ml., on the average, for about 7 days. Young et al. (1949) found that in eight of their patients a dose of 2,000,000 units gave continuous therapeutic blood-penicillin levels for 6-8 days. Neither of these groups of workers states whether their patients were A single-injection method which confined to bed. consistently gives a therapeutic effect of this duration would be particularly useful in treating outpatients with minor infective conditions since it would considerably reduce the number of injections given in the outpatient department, with obvious advantages for patients, nurses, and doctors. We have investigated the duration of therapeutic blood-penicillin levels in two main groups of patients after a single intramuscular injection of 2,000,000 units of procaine penicillin with aluminium stearate in arachis oil. It was realised that results in bed patients and ambulant patients might be different. Boger et al. (1948) and Emery et al. (1949) noted that after the injection of procaine penicillin (without aluminium stearate) the blood-penicillin levels tended to fall more rapidly in ambulant patients than in bed patients. For this reason we have compared results in these two groups. Among those included in the trial were 48 outpatients with boils, carbuncles, and minor sepsis of the hand, and in these the clinical results were noted. A’ statistical comparison of these cases with others treated in other ways was not, however, attempted. Among the surgical DR.
LONG,
DR. MILES:
REFERENCES
(continued)
Herring, P. T. (1917) Quart. J. exp. Physiol. ii, 47. Kepinov, L. (1922a) C.R. Soc. Biol. Paris, 87, 327. (1922b) Ibid, p. 494. Metalnikov, S. (1922) Ibid, p. 210. Koelsche, G. A., Kendall, E. C. (1935) Amer. J. Physiol. 113, 335. Lowenstein, B. E., Zwemer, R. L. (1943) Endocrinology, 33, 361. Marine, D., Baumann, E. J. (1945) Amer. J. Physiol. 144, 69. Miles, A. A. (1949) Brit. J. exp. Path. 30, 319. Oehme, C. (1936) Klin. Wschr. 15, 512. Sayers, G., Sayers, M. A., Lewis, H. L., Long, C. N. H. (1944) Proc. Soc. exp. Biol., N.Y. 55, 238. Scott, W. J. M. (1922) J. exp. Med. 36, 199. Squier, T. L., Grabfield, G. P. (1922) Endocrinology, 6, 85. Urbach, E., Gottlieb, P. M. (1946) Allergy. London. Wadley, F. M. (1949) Amer. Rev. Tuberc. 60, 131. Wolfram, J., Zwemer, R. L. (1935) J. exp. Med. 61, 9. Zarrow, M. X., Money, W. L. (1949) Endocrinology, 44, 345. Zwemer, R. L. (1927) Amer. J. Physiol. 79, 658. —
Abelin, I. (1944) Helv. chim. Acta, 27, 293. Bordley, J. E., Carey, R. A., Harvey, A. M., Howard, J. E., Kattus, A. A., Newman, E. V., Winkenwerder, W. L. (1949) Bull. Johns Hopk. Hosp. 85, 396. Bruce, H. M., Parkes, A. S. (1947) J. Hyg., Camb. 45, 70. Dragstedt, C. A., Mills, M. A., Mead, F. B. (1937) J. Pharmacol. 59, 359. Eickhoff, W. (1939) Virchows Arch. 303, 481. Fisher, R. A. (1947) Statistical Methods for Research Workers. Edinburgh. Flashman, D. M. (1926) J. infect. Dis. 38, 461. Gerlei, F. (1938) Endokrinologie, 19, 387. Gohar, H. A. F. (1933) J. Physiol. 80, 305. Hench. P. S., Kendall, E. C., Slocumb, C. H., Polley, H. F. (1949) Proc. Mayo Clin. 24, 181.
W. A. GILLESPIE M.R.C.P.I., D.P.H.
M.D. Dubl.,
—