THERAPEUTIC SUPPRESSION 0F TISSUE REACTIVITY
`
`I. Comparison of the Effects of Cortisone and Aminopterin
`
`.\l.D.
`By RICHARD Cuuxea,
`ASSISTANT PROFESSOR OF CLINICAL MEDICINE
`NE“! YORK, NEW YORK
`
`(From the Department of Medicine, State University of New York College of Medicine at
`Kings County Hospital. and the Equitable Life Assurance Society of
`the United States)
`
`THE remarkable advances in chemo-
`therapy in recent years have condi-
`tioned medicine of this era to consider
`disease in terms of specific cures,
`just
`as medicine of the era following Pas-
`teur and Koch became conditioned to
`view disease in terms of specific causes.
`The period intervening was one of
`elucidation and therapeutic application
`of specific host immunologic defenses.
`In this age of specific causes, specific
`responses and specific cures, general
`pathology as a conceptual guide in
`clinical medicine, which flourished so
`productively in the last century, has
`become overshadowed and some of its
`generic lessons have become obscured.
`The reaction to injury is, regardless
`of etiology, basically similar
`in its
`local manifestations, which constitute
`inflammation, both morphologicallyu
`and dynamically“, and in the general
`bodily changes largely mediated via
`stimulation of the pituitary-adrenal axis
`to which Selye“ has applied the
`terms alarm reaction and adaptation
`syndrome.
`Although the process of inflamma-
`tion is the first and most
`important
`line of defense of the body, its char-
`acteristics are such that defensive and
`reparative processes may themselves be
`inimical
`to the body’s welfare. Pha-
`gocytosis of organisms which exist
`parasitically in macrophages
`as
`in
`tuberculosis, coccidioidomycosis, psit-
`tacosis and histoplasmosis, abet and aid
`in perpetuating and disseminating the
`pathogen. Reduction in vascularity,
`
`which characterizes inflammatory pro-
`cesses of a more chronic nature, sets up
`a barrier to the penetration of hnmoral
`immune bodies or pharmacological
`agents.
`the deleterious
`is
`More important
`effect of the repair process itself, which
`like Aladdin's djinn, may wreak havoc.
`Mechanical obstruction may
`ensue
`following a lye burn of the esophagus,
`or as in cicatricial pyloric stenosis in
`peptic ulcer. Organ function may be
`impaired as in cirrhosis, uveitis, scar-
`ring of the heart valves in the wake of
`rheumatic fever, derangement of artic-
`ular and periarticular structures
`in
`rheumatoid arthritis, pulmonary fibro-
`sis secondary to silica or beryllium, to
`which may be added various granulo-
`matoses,
`to cite only random illustra-
`tions. In such circumstances disease is
`itself the repair process of the body
`stimulated to respond in such manner
`that there ensues distortion of morphol-
`ogy and interference with function.
`The reparative process is most closely
`associated with mesenchymal deriva-
`tives, notably fibroblasts and reticula-
`endothelial cells, but other organs such
`as the skin in which repair is an im-
`portant function may be similarly sub.
`ject to overactivity of the repair process
`as illustrated by keloid formation and
`the excessive desquamation of psoriasis.
`Such disorders are distinguished from
`neoplasia, which similarly may be pro-
`voked by irritative noxious agents caus-
`ing a proliferative reaction, in that they
`are responses of tissues rather than in-
`(169)
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`170
`
`GUBNERZ
`
`THERAPEUTIC SUPPRESSION 0F TISSUE REACUYITY
`
`dividual cellular elements. The distinc-
`tion, however,
`is not absolute, as is
`perhaps best illustrated by the histo-
`pathology of Hodgkin’s disease
`in
`which multiple cellular elements are
`combined in neoplastic formation.
`It appears appropriate to group such
`disorders produced by the repair pro-
`cess as diseases of
`tissue reactivity.
`Such nosological grouping in disregard
`of etiology seems warranted, for the
`musative agents, be they microorgan-
`isms, or nonorganic irritants such as
`silica, share the common property of
`acting as incitant to tissue responses of
`proliferation, which comprise the dis-
`ease entities. It is apparent that ther-
`apy in the large group of disorders
`of tissue reactivity must be directed at
`the host response and that specific
`measures aimed solely at the etiologi-
`cal agent may be inadequate and
`unavailing.
`such a concept'would
`Until recent]
`'ttle practical moment.
`have been of
`Newer knowledge of the functions of
`the adrenal cortex indicate that potent
`agents may be employed to combat the
`lesions of tissue reactivity by m '
`'
`host responses of the vulnerable shock
`tissue.
`
`The adrenal cortex, vital though it
`be in mobilizing body reactions to
`stress is, as stated by Albright‘, “anti-
`anabolic”. The lesions of Cushings
`disease are characterized by marked
`generalized atrophy of tissues, notably
`striated and smooth muscle, bone and
`skin. As indicated by Albright, this is
`due not to excessive breakdown of tis-
`sue but rather to an inhibition of tis-
`sue protein
`thesis b the glycogenic
`steroids of
`e adren . Numerous in-
`vestigations have established the inhib-
`itory
`eifect
`of
`adrenocorticotropic
`hormone (ACTH) and Compound E of
`the adrenal cortex on body growth”~”,
`and in suppressing development of
`mesenchymal tissuesz'3-3". Baker", in a
`comprehensive study, has shown that
`in addition to general
`inhibition of
`
`Page 2 of 7
`
`growth ACTH causes reduction in cel-
`lularity of
`connective
`tissue with
`atrophy of
`collagenous
`fibers
`and
`retardation of wound healing, disap-
`pearance of osteoblasts with cessation
`of proliferation of epiphyseal cells,
`atrophy of marrow,
`lymphoid struc-
`tures and the thymus, and a marked
`atrophy of the entire epithelial tissues
`including the
`epidermis,
`sebaceous
`glands
`and hair. Such suppressive
`effects on tissue proliferation provide
`an adequate explanation for the in—
`creasing number of disorders that are
`being benefited by ACTH and corti-
`sone, all of which have as their com-
`mon denominator excessive tissue re-
`activity.
`Interest in the therapeutic applica-
`tions of ACTH and cortisone has cen-
`tered particularly on the rheumatic
`diseases, largely since it was in these
`conditions that the dramatic ameliora-
`tive effects of these hormones were first
`reported by Hench and his
`co-
`workers”. Rheumafic fever and rheu-
`matoid arthritis are somewhat unique
`in that the mesenchyme is at once the
`offending agent and the victim in the
`disease process. Antibodies to hemoly-
`tic streptococcal
`infection, which are
`generated in the immune body-pro-
`ducing cells of the mesenchyme (retic-
`uloendothelial, plasma, and lymphoid
`cells), are the noxious agents that pro-
`duce the characteristic pathological
`lesions in connective tissue, another
`mesenchymal derivative". It has been
`a logical
`line of investigation to at-
`tempt to prevent the antibody response
`to hemolytic streptococcal infection in
`treating rheumatic fever, and evidence
`has accumulated suggesting that
`the
`beneficial action of massive salicylate
`therapy may be due to suppression of
`the immune responseWL“. The adrenal
`cortical hormone in large doses sup-
`presses
`antibody formation experi-
`mentally”, and it has been su
`ested
`that this may be a mechanism w ereby
`cortisone alleviates rheumatoid arthritis
`
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`

`GUBNBR:
`
`THERAPEUTIC SUPPRESSION 0F TISSUE REACTIVITY
`
`171
`
`and allied conditions”. In man, how-
`ever, neither ACTH nor cortisone in-
`hibits antibody formation“. Numerous
`studies indicate furthermore that corti-
`sone operates
`by suppressing the
`reactivity of connective tissue itself
`rather
`than by acting at
`the level
`of immune responses. Thus there may
`be mentioned
`suppression
`of
`the
`Schwartzman Phenomenon” and of
`connective tissue responses
`to such
`local irritants as beryllium dust“ and
`formalin periarthritis‘“ where immune
`mechanisms are not involved.
`Although suppression of antibody
`formation may be produced experi-
`mentally by agents such as salicylate,
`adrenal cortical hormone, and amin-
`opterin“, this cannot be readily accom-
`plished in man, and it is probable that
`the depression in blood globulins ob-
`served with cortisone
`and ACTH
`reflects the general inhibition] of protein
`synthesis earlier reported by Albright‘,
`rather than any specific effect on anti-
`body formation. Neither nitrogen mus-
`tard,
`spray radiation, urethane nor
`aminopterin produce any lowering of
`gamma globulin in rheumatic fever
`or rheumatoid arthritis“.
`Aminopterin does, however, despite
`the lack of any indication of effect on
`immune responses. produce ameliora-
`tion of symptoms and decrease in
`articular and periarticular exudative
`changes. In a study carried out in col-
`laboration with Dr. J.
`]. Oleson of
`the Lederle Laboratories it has been
`found that
`in rats pretreated with
`aminopterin there is suppression of
`emdative and proliferative changes
`produced by periarticular injection of
`formalin, similar to the findings re-
`ported by Selye with cortisone“. In
`these experiments male albino rats
`weighing 70 to 85 gm. received 10‘!
`of aminopterin divided into 2 oral
`doses daily. On the second day 0.1 cc.
`1% formaldehyde was injected into the
`right hind paw at the plantar aponeuro-
`sis. This injection was repeated on the
`
`Page 3 of 7
`
`4th day, and on the 5th da an injec-
`tion of 0.1 cc. of 2% formal ehyde was
`given at the plantar aponeurosis of the
`left hind paw. Severe inflammatory
`reaction and marked swelling of the
`hind feet occurred in control animals,
`which was largely although not en-
`tirely suppressed in the animals receiv-
`ing aminopterin. The inhibitory effect
`of aminopterin on formalin arthritis
`occurred in adrenalectomized animals,
`so that the suppression of the inflam-
`matory response was directly due to
`aminopterin and not mediated via
`adrenal
`stimulation. A somewhat
`greater
`suppression of
`inflammatory
`changes was observed in 2 rats given
`cortisone in dosage of 5 mg. divided
`into 4 daily doses. The steroid artisone
`in the same dosage was devoid of any
`effect.
`Indication of the suppressive effect
`of aminopterin on tissue reactivity is
`seen clinically, particularly in psoriasis
`where the therapeutic response is more
`uniform and more dramatic". Histolog-
`ically psoriasis is characterized by a
`great overgrowth of
`the epithelium.
`with downward growth of the interpa-
`pillary processes“. It is of interest that
`improvement in psoriasis ha been ob-
`served on administration of cortisone“.
`In 18 subiects treated with aminop—
`terin in daily dosage of 1 to 2 mg.
`numerous indications of an inhibition
`of tissue reparative and proliferative
`responses have been observed. In 10
`subiects with psoriasis, cessation of
`scaling has occurred regularly within
`3 to 7 days, frequently accompanied by
`slight hemorrhagic crusting at the site
`of the lesions followed by rapid thin~
`ning of the skin in the areas involved.
`Similar changes in skin lesions have
`been observed in a case of lupus ery-
`thematosus and in a subject with chron-
`ic atopic eczematoid dermatitis. In the
`latter the observation was made by the
`patient
`that his associated asthma.
`which for several months had required
`2 injections of 0.3 to 0.6 mg. epin-
`
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`

`172
`
`Gunman:
`
`THERAPEUTIC SI'I'I'RI'ZSSIOX OI" TISSUE REACTIVITY v
`
`ephrine and 7 to 8 capsules of ephed-
`rine daily,
`improved so markedly
`during the period of aminopterin ad-
`ministration that no therapy other than
`an occasional ephedrine capsule was
`required. Three weeks after discontinu-
`ing aminopterin his dermatitis and
`asthma both recurred and an identical
`response was obtained with a 2nd
`course of aminopterin given in dosage
`of 1.5 mg. daily for 11 days.
`In 4 subjects temporary incomplete
`alopecia
`followed administration of
`aminopterin. Hair
`loss
`is produced
`likewise by ACTH2. Lack of healing
`was a noteworthy finding in 3 subjects
`with superficial ulceration of the scro-
`tum, penis and neck respectively, and
`in 2 patients with pustular infections.
`In these subjects absence of granula-
`tion and epithelialization was conspicu-
`ous and bleeding occurred with any
`rubbing of the wound surface. Impair-
`ment of wound healing has likewise
`been observed with ACTH and corti-
`soneg-mi Further indication of inhibi-
`tion of connective tissue proliferation is
`seen also in the suppressive effect of
`aminopterin on experimental sarcoma
`27'3””. an effect that is also exhibited
`by cortisonefl.
`A uniform finding among patients
`treated with aminopterin was the oc-
`currence of patches of shallow ulcera-
`tion of the buccal mucosa generallv as-
`sociated with abdominal cramps. These
`changes generally developed during
`the 2nd week of aminopterin adminis-
`tration after a total dose of 10 to 20
`mg., although in a few instances as
`much as 40 mg. was given before
`changes in the oral mucosa or cramps
`developed. These findings are due. iust
`as in the skin. to inhibition of prolifer-
`ation of epithelium in the oral cavitv
`and gastrointestinal tract, the mucosal
`thinning favoring the development of
`superficial
`infection and ulceration.
`Similar observations have been made in
`rats and dogs given aminopterin”, and
`also in man, in patients with acute leu-
`
`kemia, in whom temporary remissions
`followed by refractoriness may be ob-
`served‘-“‘-"3, similar to experience with
`ACTH and cortisone”.
`\Veight
`loss
`and muscle wasting, which are pro-
`duced experimentally by aminopterin”.
`and are also seen with experimental
`administration of ACTH“. and in the
`.hyperadrenalcorticism of Cushing's dis-
`ease, were observed in 1 subject given
`40 mg. of aminopterin over a 3 week
`period.
`It is not
`intimated from these an-
`alogous effects of aminopterin and
`cortisone that
`their actions are the
`same. Both are anti-anabolic, but cor-
`tisone is concerned with whole protein
`moieties”; whereas the locus of action
`of the folic acid antagonist aminopterin
`lies more particularly in inhibition of
`the effects of folic acid on the synthe-
`sis of purines, pyrimidines and desoxy-
`ribonucleic acidT-W‘, and the utilization
`of tvrosine. histidine, and other amino
`acids in the regulation of protein syn-
`thesislaJlSJDJB.
`Folic acid is now recognized as
`essential
`in nucleoprotein formation
`and cell growth, acting as a coenzyme
`in enzyme systems concemed with syn-
`thesis of thymine and purines“. The
`effect of aminopterin is to block the
`reduction of folic acid to the formation
`of the citrovomm factor, which is the
`biologically active derivative of folic
`acid5-‘7.
`Observation that the citrovonlm fac-
`tor or thvmidine reverses the inhibiton'
`effect of aminopterin-“7 has provided
`a useful means to control some of the
`toxic effects of aminopterin.
`In the
`present
`study citrovorum factor
`in
`dosage of 40 to 100 million units was
`given intramuscularlv 2 to 3 times
`weekly to 4 subiects receiving aminop—
`terin. An increased tolerance to amin-
`opterin was observed. as compared to
`previous courses of aminopterin ad-
`ministration several months
`earlier.
`There was partial but not complete
`protection from the typical toxic effects
`
`Page 4 of 7
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`

`urnxrzu:
`
`TIIERAI'I-II'TIC SI'I‘I’RESSION 0F TISSUE REACTIVITY
`
`173
`
`of aminopterin, that is, stomatitis and
`abdominal cramps, but
`it was also
`observed that
`the
`amelioration of
`arthritic symptoms and of psoriasis was
`less complete than when aminopterin
`alone had been given. Aureomycin
`given prophylactically in several sub-
`jects in dosage of 1 gm. daily was
`found effective in decreasing stomati-
`tis and gastrointestinal symptoms and
`did not appear to modify sensibly the
`therapeutic effect of aminopterin.
`Although the citrovorum factor and
`aureomycin are helpful
`in alleviating
`the toxic effects of aminopterin the
`margin between the therapeutic and
`toxic (lose of aminopterin is so narrow
`as to preclude its clinical use. The
`observations of an ameliorative effect
`on the exudative phenomena of rheu-
`matoid arthritis reported separatelv in
`greater detail” are of interest princi-
`pallv to indicate that the mechanism
`of action of cortisone is not a specific
`hormonal effect but is due to suppres-
`sion of mesenchvmal reactivity. as is
`also accomplished bv aminopterin. It
`is to be emphasized that the effects of
`aminopterin are not so marked as those
`nrodueed bv cortisone, although the
`action
`is more protracted usuallv
`persisting for some weeks after dis-
`continuing medication. Sustained phar-
`macolmrical effect is a desideratum in
`controlling diseases of tissue reactivity
`and it is possible that other anti-folio
`compounds will be found more suitable
`for clinical employment. or that ami-
`nopterin in smaller dosage may be 11se-
`ful
`as
`a
`supplement
`to cortisone
`administration. The use of such meas-
`ures mav be envisaged as a potent
`therapeutic weapon to suppress the
`unfavorable host
`responses of tissue
`reactivitv, in coniunction with specific
`measures
`aimed at
`the
`etiological
`agent. Thus.
`for
`example, ACTH
`nromptlv
`suppresses
`granulomatous
`formation and ulceration of- laryngeal
`lesions, and svstemic signs of illness, in
`tuberculosis“. The administration of
`
`inhibit unfavorable host
`agents that
`responses in tuberculosis over extended
`periods may prove of considerable
`value as an adjunct to specific chemo-
`therapy with streptomycin and other
`bacteriostatic agents.
`Both cortisone and aminopterin exert
`generalized effects on all
`tissues;
`this
`limits their therapeutic value. A studv
`is currently in progress to establish
`whether
`the striking remissions
`in
`psoriatic lesions observed with oral ad—
`ministration of aminopterin can be
`achieved by topical applications
`so
`that
`the effects of the drug can be
`confined to the tissues involved. If, as
`appears probable, the beneficial effect
`of such measures as cortisone and
`aminopterin in the rheumatic state is
`due to suppression of mesenchymal
`reactivity it would appear desirable to
`find an agent that specifically inhibits
`connective tissue. Such a substance
`has been found in extracts of malt,
`ungerminated grain and oranges, which
`totallv inhibit the growth of fibroblasts
`and other mesenchvrne cells in con-
`centrations permitting the free growth
`of epithelial
`tissues”. Further study
`has revealed this differential growth-
`inbibiting action to he possessed by
`parasorbic acid and coumarin’”. It is
`of interest that coumarin is structurally
`allied to salicylate. It would appear
`worth while to investigate the thera-
`.peutic potentialities of parasorbic acid
`and various of the coumz‘irin series.
`Considerable investigation has been
`done in the screening of therapeutic
`agents in experimental sarcoma. and
`this line of investigation may prove V
`fruitful in finding connective tissue in-
`hibiting agents of value in diseases
`involving mesenchymal tissues such as
`resnond to cortisone.
`Summary.Attention is drawn to the
`similarity1n action of cortisone and the
`folic acid antagonist aminopterin. Al-
`though the locus of their biochemical
`effects does not appear to be the same.
`both are anti-anabolic and inhibit tis-
`
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`171
`
`aunxnn:
`
`THERAI’EUTIC SUPPRESSION 01" TISSUE REACI‘1"1TY
`
`are
`regeneration. Observations
`sue
`reported
`indicating
`the
`inhibitory
`effect of aminopterin 011 various tissue
`elements. Amelioration of psoriasis,
`and of experimental and clinical
`ar—
`thritis, reflects suppression of epithelial
`and mesenchymal derivatives respec-
`tively.
`Clinical disorders in which reparative
`and proliferative host
`responses are
`inimical to the body’s welfare may be
`
`nosologically grouped as diseases of
`tissue reactivity. In such disorders sup-
`pression of
`tissue reactivity, which
`itself constitutes the disease process,
`becomes a therapeutic necessity. The
`therapeutic rationale of agents that
`suppress tissue reactivity such as cor-
`tisone and anti~folic com ounds, and
`of other compounds who may more
`selectively affect mesenchyme,
`is dis-
`cussed.
`
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