H. M. POLLARD. Arbor, Mich.) crease the excretion of this substance. Furthermore, poor index of gastric secretory activity for reasons

Transcription

1 EFFECTS OF EIGHT-HOUR INTRAVENOUS INFUSIONS OF ACTH AND THE ADRENOCORTICAL STEROIDS IN NORMAL MAN. I. BASAL GASTRIC SECRETION, AND PLASMA AND URINARY PEPSINOGEN 1, 2 By B. I. HIRSCHOWITZ, D. H. P. STREETEN,3 J. A. LONDON, AND H. M. POLLARD (From the Deprtment of Internl Medicine, University of Michign Medicl School, Ann Arbor, Mich.) (Submitted for publiction November 12, 1956; ccepted Mrch 28, 1957) While there ppers to be generl greement tht drenocorticl deficiency results in reduction of gstric secretory ctivity both in mn (1-6) nd in nimls (7-11), no such unnimity of opinion exists regrding the effects of incresed ctivity of the drenl cortex on gstric secretion. Wheres some studies hve shown tht the dministrtion of ACTH or of drenocorticl steroids my increse gstric cid nd pepsin secretion (12-14), others hve filed to show ny significnt increse in cid or pepsin output by the stomch during the dministrtion of ACTH (15-17) or cortisone or hydrocortisone (18, 19). Prt of the confusion regrding ny stimulnt effect of incresed drenocorticl ctivity stems from the use of urinry pepsinogen (uropepsin) levels s n index of gstric secretion. In this study the effects of 8-hour infusions of ACTH, hydrocortisone, corticosterone, prednisolone, nd ldosterone in norml mles on the volume, cid, pepsin, nd viscosity of gstric juice were studied, together with simultneous mesurements of blood nd urinry pepsinogen. These results were compred with the effects of infusion of the vehicle lone nd contrsted to the effects of 4-hour infusion of histmine. The results indicte tht in generl the hormones did not produce stimultion of gstric secretion compred with known stimulnt such s histmine. An nlysis of chnges in urinry pepsinogen excretion indictes tht the glucocorticoids in- 1 Presented before the Ntionl Meeting of the Americn Federtion for Clinicl Reserch t Atlntic City, My 1, Supported in prt by grnt from the United Sttes Public Helth Service (RG 4298) (c) nd in prt by grnt from the Horce H. Rckhm School of Grdute Studies. 'Investigtor for the Howrd Hughes Medicl Institute. crese the excretion of this substnce. Furthermore, urinry pepsinogen hs been found to be poor index of gstric secretory ctivity for resons which re discussed below. METHODS Sixteen norml dult mle students were studied in the fsting stte. In 15 of these subjects, ech experiment ws strted between 7 nd 8 A.M.; in the other, the experiments strted t 11 A.M. To serve s control period, the vehicle lone (1 per cent ethyl lcohol, 2.5 per cent dextrose, nd.45 per cent NCl in wter) ws infused for 3 hours, followed for 8 hours by the infusion of 25 interntionl units of corticotropin (ACTH), 1 mg. hydrocortisone (F), 1 mg. corticosterone (B), 25 mg. prednisolone (A-F), or 4 ftg. ldosterone in 1, ml. of the vehicle, followed in turn by further 2 hours of infusion of vehicle. Thirteen subjects received ACTH; 11, hydrocortisone; 9, corticosterone; nd 13, the vehicle lone. Eight subjects ech hd ll four experiments, 2 of these lso receiving prednisolone, nd one of the ltter n infusion of ldosterone s well. In further experiments on 6 of these subjects nd 4 others, 1.2 mg. histmine bse (s the diphosphte) in 5 ml..9 per cent sline ws infused over 4 hours fter one-hour control period. Gstric tubes were pssed either orlly or nslly ccording to the subject's preference, nd the gstric end positioned under fluoroscopic control in the proximl prt of the pyloric ntrum t the strt of the experiment. At the end of ech experiment the tube ws gin checked for position, nd in no instnce hd it shifted significntly. Continuous spirtion of the stomch ws mintined through the experiment nd supplemented t hlf-hour intervls by hnd suction with syringe. The consecutive hlf-hour smples of gstric juice were nlyzed for free H+ ion by-electrometric titrtion to ph 3.3 ginst.1 N NOH; the smples were then refrigerted nd t the end of ech experiment they were centrifuged for 15 minutes t 2,5 rpm nd the viscosity of the supernte mesured immeditely t room temperture by mesuring the time tken for column of gstric juice to fll between two fixed points in stright cpillry tube (using.2 ml. fluid) (15),. To determine the pproximte -chnges in mucin concentrtion 1171

2 1172 B. I. HIRSCHOWITZ, D. H. P. STREETEN, J. A. LONDON, AND H. M. POLLARD which might be responsible for the observed vritions in viscosity of gstric juice by this method, the viscosity of series of dilutions of hog mucin (Wilson 171-W) in.4 N HCO ws mesured (Figure 1). In order to estblish the vlidity of mesuring the viscosity of the gstric juice by this method, the results of 127 smples from some of these experiments were compred with vlues obtined with n Ostwld viscometer (using 3.5 ml. fluid) t 37 C. in the sme smples. The results, in terms of wter s unity, were strictly comprble nd correltion coefficient gve n 'ry vlue of The stndrd error of 25 replicte mesurements of one smple ws ±.14 per cent of the men. The viscosity redings were not influenced by centrifugtion t 2,5 rpm for periods rnging from 1 to 5 minutes fter the initil centrifugtion, suggesting tht the substnces imprting the extr viscosity were in solution. Bile contmintion in the mounts observed hd no pprecible effect on the viscosity of gstric juice. It should be dded tht the method employed here is not recommended for compring different fluids, but ppered to be dequte for the seril determintion of the viscosity of gstric juice. Icteric index nd pepsin concentrtion of the gstric juice were mesured the next morning, the former by the method described for plsm (2), the ltter using 2 per cent hemoglobin substrte nd 1: 5 dilution of gstric juice (21). The totl eosinophil count, employing phloxine stin, nd the plsm pepsinogen (21) content of blood smples collected every 2 hours were determined. Smples of urine collected overnight before ech nd fter most experiments nd every 2 hours during ech experiment were ssyed for pepsinogen by the hemoglobin method (22), modified only by extending the incubtion time to 3 minutes. Urinry 17-hydroxycorticoids (23) were mesured in the ACTH experiments only. Contmintion by sliv ws reduced by hving the subjects expectorte t frequent intervls. The icteric index of the gstric juice ws used s some mesure of the degree of duodenl regurgittion, in preference to continuous dringe of the duodenum by second tube, which would require frequent fluoroscopic control nd which of itself my stimulte gstric secretion (24). When the cid nd pepsin concentrtions, respectively, were plotted ginst the icteric index it ws found tht norml duodenl regurgittion hd no consistent effect on the concentrtion of either cid or pepsin. The icteric index ws under 8. in 96 per cent of smples nd under 3. in 8 per cent of smples in ll the experiments. With this ressurnce of the miniml role of duodenl regurgittion in neutrlizing or diluting the gstric juice, ll the smples were included in the clcultions regrdless of their bile contmintion. Clcultions nd sttisticl methods. In clculting the results, both the outputs nd the men concentrtions of cid nd pepsin for ech hourly period were derived from the consecutive hlf-hour smples. The men vlues include ll the hourly smples in ech 2 or 3-hour period in ll the subjects. Thus, for 13 experiments 39 smples were used to clculte the men nd the stndrd devition (S.D.) in the 3-hour control period nd 26 smples in ech successive 2-hour period. Becuse of the smll numbers of figures in the prednisolone nd ldosterone experiments these mens hve not been subjected to sttisticl testing. To determine the vribility in consecutive hourly collections of gstric juice volume, cid nd pepsin output in the 13 vehicle (control) experiments, the coefficient of vrition for ech prmeter in ech subject ws clculted. The men (± S.D.) of the coefficients of vrition for volume ws 34 per cent ± 9 per cent; for pepsin output 35 per cent + 6 per cent; nd for HC1 output 67 per cent ± 31 per cent. The greter vribility in HC1 output ws due to the reltively lrge fluctutions in those subjects with the lowest output (under 1 meq. per hr.); the higher the output, the stedier ws the rte of secretion. RESULTS Eosinophil nd 17-hydroxycorticoid responses (Tble I) All the subjects given ACTH hd n dequte drenocorticl response s judged from the rise TABLE I Effect of intrvenous infusions () on circulting eosinophils nd (b) of A CTH on urinry excretion of 17-hydroxycorticoids Control period During infusion After infusion Substnce -- InfUsed -3 hr. Ohr. -2hr. -4 hr. -6 hr. -8Shr. +2 hr. +3 hr. +l2 hr. () Men totl eosinophil count (cells/cu. mm.ds.d.) Vehicle 193=1:1 O : : : 17 ACTH i = : d: 6 Corticosterone 1674: 4L9 149: : = : 1:54 Hydrocortisone 175k.S =178 54:45 21h :11 Prednisolone Aldosterone I (b) Men urinry excretion of 17-hydroxycorticoid (mg./hr.=es.d.). ACTH (Overnight.151:.3).58:.7.82= : :1..865S

3 ADRENAL CORTE AND GASTRIC SECRETION 1173 TABLE II Effect of intrvenous infusions on volume of gstric juice Men volume of gstric juice (mi./hr.-s.d.) Control period During infusion After infusion Substnce No. of infused studies 3 hr. o-2 hr. -4 hr. -6 hr. -8 hr. +2 hr. Vehicle ACTH * 78E38t Corticosterone A19* * 52416* 65i29t Hydrocortisone Prednisolone L (5 hr.) Aldosterone (4 hr.) (1 hr.) (2 hr.) (3 hr.) (4 hr.) Histmine I.V i51t t t 22d94t (lhr.) * p <.5 O Significnce of increse over control period by Student's 't' test. All other differences from control t p <.11 periods re not significnt. in 17-hydroxycorticoids nd the fll in circulting eosinophils. A similr eosinophil response ws elicited by the dministrtion of hydrocortisone nd prednisolone. No significnt eosinophil chnges were noted with the vehicle infusions or following the dministrtion of corticosterone or ldosterone. Volume of gstric juice Tble II detils the men hourly volume of gstric juice spirted in the 3-hour control period nd in ech succeeding 2-hour period of the experiments. The volumes were significntly incresed over the control period in the lst 2 hours of ACTH infusion nd in the succeeding 2 hours, s well s during the entire period (except the second 2 hours) of the corticosterone infusion nd in the 2 hours following its infusion. The mgnitude of these increses, though sttisticlly significnt, did not pproch 25 per cent of the increses noted with histmine. There were no significnt increses in the volume of gstric secretion in either the vehicle or in the hydrocortisone or the prednisolone experiments. Output of hydrochloric cid (Tble III) The output of cid did not chnge significntly from the corresponding control vlues during the infusion of ny of the hormones. The only sttisticlly significnt rise in the output of cid occurred in the 2 hours fter the end of the corticosterone infusion. Even in this period, however, the ctul output of cid ws of the sme order of mgnitude s in the corresponding period of the LE III Effect of intrvenous infusions on gstric output of hydrochloric cid Men gstric output of HC1 (meq./hr.±s.d.) Control After period During infusion infusion Substnce No. of infused studies 3 hr. -2 hr. -4 hr. -6 hr. -8 hr. +2 hr. Vehicle ACTH Corticosterone : t Hydrocortisone i Prednisolone * (5 hr.) Aldosterone E t (4 hr.) (1 hr.) (2 hr.) (3 hr.) (4 hr.) Histmine t 24.8.E8.t 24.4E1.6t t (1 hr.) * p < 5.Significnce of increse over control period by Student's 't' test. Other differences not significnt.

4 1174 B. I. HIRSCHOWITZ, D. H. P. STREETEN, J. A. LONDON, AND H. M. POLLARD TABLE IV Effect of intrvenous infusions on output of gstric pepsin Men output of gstric pepsin (P.U. (thousnds) per hour hs.d.) Control period During infusion Afterinfusion Substnce No. of infused studies 3 hr. -2 hr. -4 hr. -6 hr. -8 hr. +2 hr. Vehicle ACTH t Corticosterone * t t t Hydrocortisone d Prednisolone (5 hr.) Aldosterone (4 hr.) (1 hr.) (2 hr.) (3 hr.) (4 hr.) Histmine i476t t 218=78t t (1 hr.) * p <.5 Significnce of increse over control period by Student's 't' test. All other differences from men control t P <.1 not sttisticlly significnt. vehicle experiments. Furthermore, none of the men vlues of cid output pproched 2 per cent of the sustined levels during the histmine infusion. Output of pepsin (Tble IV) There ws smll, progressive increse in the output of pepsin in ll of the experiments, except those in which hydrocortisone ws infused. When compred with the vlues during the corresponding control periods, the pepsin output ws significntly incresed during the lst 6 hours of the corticosterone infusion nd fter the end of the infusions of corticosterone nd of ACTH. The ctul output of pepsin in the hormone experiments, however, ws lwys lower thn in the corresponding periods in the vehicle experiments, nd the bsolute increses observed in the hormone experiments were never greter thn 25 per cent of the increses which occurred with the histmine infusions. The composition of gstric juice The over-ll secretory ctivity of the stomch s judged by the output of wter, cid, nd pepsin remined substntilly unltered under the in- TABLE V Effect of intrvenous infusions on concentrtion of hydrogen ion nd pepsin in gstric juice Control After period During hormone infusion infusion Substnce Infused 3 hr. O-2 hr. -4 hr. -6 hr. -8 hr. +2 hr. Men H+ concentrtion (meq./liter) Vehicle ACTH Corticosterone Hydrocortisone Prednisolone Aldosterone (1 hr.) (2 hr.) (3 hr.) (4 hr.) Histmine Men pepsin concentrtion (P. U./ml.) Vehicle 1,233 1,262 1,43 1,639 1,494 1,521 ACTH 1,13 1,18 1,62 1, Corticosterone 1,418 1,377 1,641 1,626 1,7 1,571 Hydrocortisone 1,26 1,332 1,217 1,2 1,67 1,67 Prednisolone 1,83 1,138 1,576 1,562 1,147 Aldosterone 944 2,31 2,2 2,265 2,36 1,36 (1 hr.) (2 hr.) (3 hr.) (4 hr.) Histmine 936 1,289 1,84 1,85 1,272

5 ADRENAL CORTE AND GASTRIC SECRETION 1175 TABLE VI Efect of intrvenous infusions on viscosity of gstric juice Men eereding (seco+s.d.) (Wter 7.35:.5 sec.) After Control During Infusion infusion Substnce No. of infused studies 3 hr. -2 hr. -4 hr. -6 hr. -8 hr. +2 hr. Vehicle * * *1.3 ACTH * * * 7.82s.55t t Corticosterone *+.27* Hydrocortisone * * * *: *1.2 Prednisolone Aldosterone * p <.5 Significnce of decrese from control vlue by Student's 't' test. Other differences not significnt. t p <.1~ fluence of the 8-hour infusion of ACTH or dreno- Concentrtions of cid nd pepsin (Tble V) corticl steroids. However, there were some sig- There ws essentilly no difference between the nificnt chnges in composition of the gstric concentrtions of cid in ny of the hormone exjuice. periments nd in their own control periods or in SECONDS 11.5/ 11. s =~~ IO 'W~eto (735t.5) -.2±.).4 i I.. 1. % CONCENTRATION OF MUCUS FIG. 1. VIscoxsrER READINGS OF INCREASING CONCENTRATIONS OF WILSON HOG STOMACH MUCIN (171-W) IN.4 N HCL, IN THE RANGE OF OBSEREvD GASTRIC JUICE VISCOSrrY

6 1176 B. I. HIRSCHOWITZ, D. H. P. STREETEN, J. A. LONDON, AND H. M. POLLARD TABLE VII Effect of intrvenous infusions on concentrtion of pepsinogen in plsm Men pepsinogen concentrtion (P.U. per 1 mi. hs.d.) After Control period During infusion infusion Substnce No. of infused studies -3hr. Ohr. 2 hr. 4hr. 6hr. 8hr. +2 hr. Vehicle ± ± ±5.1 ACTH ± ± i ±5. 1.6± Corticosterone ± ±3. 1.5± ± ±7.5 Hydrocortisone ± ± ± ± Prednisolone Aldosterone the vehicle experiments. With infusion of the progressive fll in viscosity which becme mnivehicle lone, the concentrtion of pepsin tended fest in the first 2 hours of infusion, sttisticlly sigto rise s the experiment progressed. There ws nificnt by the sixth hour, nd highly significnt in persistent but smller rise in the concentrtion of the following 4 hours. There ws generl tendpepsin with the infusion of corticosterone, nd no ency for the viscosity to fll in the other experiessentil chnges in concentrtion with the infu- ments, but only in the lst 2 hours of the corticossion of ACTH or of hydrocortisone or predniso- terone infusion ws this fll sttisticlly significnt. lone. The most striking chnges occurred with In generl, the decrese in viscosity, representthe infusion of ldosterone, during which the con- ing presumbly dissolved mucus, ws lso obcentrtions of pepsin nd cid more thn doubled. served in visible mucus. This ws especilly ob- Such n increse in pepsin concentrtion ws not vious with the ACTH infusions, during which observed in ny other experiment. visible mucus tended to dispper from the gstric Viscosity of gstric juice juice. The norml viscosity of gstric juice is little Plsm pepsinogen concentrtions higher thn wter (Tble VI) but reltively smll chnges in viscosity of the fluid represent, in terms There ws no significntvritionin plsm of stndrd solution of mucin, reltively lrge pepsinogen concentrtion in ny of the experichnges in concentrtions of dissolved mucus ments (Tble VII), nd ll the subjects hd levels (Figure 1). which were well within the norml rnge (25). The infusions of vehicle produced no significnt This stbility contrsted with the rther mrked chnges in viscosity compred to the control pe- chnges in excretion of pepsinogen in the urine, riod. Under the influence of ACTH there ws described below. TABLE VIII Effect of intrvenous infusions on urinry excretion of pepsinogen Men urinry pepsinogen (P.U./hr. *S.D.) During infusion Substnce No. of Overnight Control Overnight infused studies before 3 hr. -2 hr. -4 hr. -6 hr. -8 hr. +2 hr. fter Vehicle 12 89±64 13±48 115± ± 42 17± 4 117± ± 74 ACTH ±92 196±112 22± ± 83t 222±18 148±54 Corticosterone 9 91±56 137±83 123± ± ± ±19 145± 87 16±73 Hydrocortisone ±57 196± 84t 251±165t 379±429t 248±119t 255±17t 171±79 Prednisolone* Aldosterone* * Sme subject. t P <g.}significnce of increse over control period. Other differences not significnt.

7 z O E z V) 4 ADRENAL CORTE AND GASTRIC SECRETION 1177 hydrocortisone ws sttisticlly significnt increse over the control period, from the second hour of the hormone infusion until the 2-hour period fter the completion of the infusion. With corticosterone, 5 of the 9 subjects showed smll increse in pepsinogen excretion, but the men showed no significnt increse for the group over the control period. With ldosterone there ws drop in urinry pepsinogen excretion, nd with prednisolone n increse in the one experiment where urinry pepsinogen ws mesured. The effects of hydrocortisone persisted during the night fter the infusion, wheres the effects of the other hormones did not continue for more thn 2 hours fter their infusion. z22 w ( M b - CONTROL 1 2 HOURS 4 OF INFUSION +2 CONTROL FIG. 2. MEAN EFFECTS OF VARIOUS INFUSIONS ON THE RENAL CLEARANCE OF PEPSINOGEN Urinry pepsinogen excretion (Tble VIII) The urinry pepsinogen excretion in the vehicle experiments remined firly constnt during the dy, with slightly lower overnight level. The coefficients of vrition of the dy smples in 12 vehicle experiments rnged from 1 per cent to 45 per cent with men of 22.8 per cent 14. There ws less vrition within individuls thn between individuls, nd it ws felt tht 2-hour smpling ws ccurte enough despite lrge vritions in urine volume (26, Tble I). Under the influence of ACTH there ws rise in urinry pepsinogen output within 2 hours, reching plteu by the sixth hour. No subject filed to experience moderte to lrge increse in pepsinogen excretion under the influence of ACTH. With hydrocortisone 2 of the 1 subjects hd no increse in urinry pepsinogen excretion. However, the men response to the infusions of The clernce of pepsinogen The clculted renl clernces of pepsinogen indicte, s would be expected from the plsm nd urinry pepsinogen figures, tht hydrocortisone more thn doubled the clernce, nd tht ACTH cused moderte increse (Figure 2). The reltion of urinry pepsinogen to glucocorticoid ctivity Comprison of the output of urinry pepsinogen with tht of 17-hydroxycorticoids in the ACTH experiments showed some ssocition between the two (r = +.43, n = 55, p <.1). Furthermore, the men urinry pepsinogen excretion nd men totl eosinophil counts showed n excellent negtive liner correltion (r =-.88, p <.1), (Figure 3). Reltion of urinry pepsinogen to gstric pepsin secretion In ech experiment on ech subject the output of pepsinogen in the urine ws compred with the output of pepsin into the stomch, in three periods comprising, respectively, the entire control period preceding, the 8 hours during, nd the 2 hours following the hormone infusion. These dt (Figure 4) show no correltion between urinry pepsinogen excretion nd the simultneous secretion of pepsin into the stomch. The clculted rtios of Gstric pepsin: Urinry pepsinogen for these periods showed very wide fluctutions rnging from 88: 1 to 2,65: 1 with men rtio in the

8 1178 B. I. HIRSCHOWITZ, D. H. P. STREETEN, J. A. LONDON, AND H. M. POLLARD E 251. I U)-- 2J -J w -lso U) i ACTH A * I:IYDROCCORTISONE \( CORTICO)STERONE _ Y * -.76+#237 R * -.88 L I I z nia 4i 4c - - P\. t~~~~~~~ ^~~~ URINARY PEPSINOGEN PU / HOUR FIG. 3. NGATIVE CO TION BErWEN THE MEAN ABSOLUTE EOSINOPHIL COUNT AND SIMULTANEOUS URINARY PEPSINOGEN ECRETION Ech coordinte represents the men vlues t successive periods in the respective experiments (see Tbles I nd VIII). )ON x 25 x x 2. A z IL so 5-1 Al u9 FIG. 4. * 4 )6 t o o.t. * * f So. * A C. S A x I --I* I* I I 1 * URINE PEPSINOGEN PU / HR. * * VEHICLE F * ACTH LACK of CRRELATION BETWEEN THE OUTPUT OF PEPSIN IN THE GASTRIC JUICE AND SIMULTANEOUS URINARY PEPSINOGEN ECREON (SEE TET)

9 control period of 83: 1. Both ACTH nd hydrocortisone produced considerble drop in this rtio during the 8 hours of their infusion to men of 35: 1, becuse of the increse in urinry pepsinogen out of proportion to ny chnge in gstric pepsin secretion. DISCUSSION Role of drenl cortex in gstric secretion ADRENAL CORTE AND GASTRIC SECRETION Rowntree nd Snell (1) showed tht hydrochloric cid secretion ws depressed or bsent in Addison's disese, nd Escmill nd Lisser (2) tht the sme ws true in Simmonds' disese. The mechnisms whereby the drenocorticl secretions mintin norml gstric secretion re not cler. The gstric hypofunction in Addison's disese my (4) or my not (3) be ssocited with gstric mucosl trophy s judged by gstroscopy. Secretion in both cses ws restored to norml by cortisone, with return to norml of the mucos in the former instnce (4). In nimls there is evidence tht both pituitry (9) nd drenl insufficiency (7-9) result in impirment of gstric secretion, nd tht the decrese in pepsin secretion is ccompnied by involution of the chief cells with loss of ribonucleic cid (8, 9). Confirmtion of this involution, noted histologiclly, ws obtined by chemicl nlysis for pepsinogen which ws decresed in the mucos of the stomchs of drenlectomized rts (11). Restortion of secretion with drenl cortex extrct (7) nd of norml synthesis of pepsinogen by cortisone, corticosterone, hydrocortisone, nd desoxycorticosterone, s well s by corticl extrct (11), indictes the reltively nonspecific steroid requirements of the chief cells for norml function. It would thus pper tht the drenocorticl secretions re necessry to mintin both structurl nd functionl integrity of the gstric mucos, probbly cting in permissive (6) or trophic role. On the other hnd, the evidence in support of stimulnt role for the drenl cortex in gstric secretion is both indequte nd conflicting. Gry nd his collegues hve climed such role for the drenl both in cute (13) nd in chronic experiments (12, 27, 28). In the published evidence presented by these uthors mny of the vlues for gstric juice volume, cid nd pepsin re within 1179 the limits of fluctution in the bsl stte, nd where significnt increses were noted, these were usully in the second or third week of sustined high drenocorticl ctivity. The observtions of these uthors re supported by the finding in four dogs of moderte, though inconsistent, increse in cid output while the nimls were being given lrge doses of ACTH (14), nd by unconvincing evidence of hypersecretion of cid in Cushing's syndrome (5). Moreover, much of the evidence for n increse in gstric secretion produced by ACTH nd the drenocorticl steroids is indirectly derived from the increse in urinry pepsinogen excretion under the influence of these hormones (27, 28). As hs been shown before (15, 29) nd gin in this pper, the rise in urinry pepsinogen is not reflection of similr chnges in gstric secretion. In contrst with the findings of Gry nd his ssocites (12, 13, 27, 28), Kirsner nd Ford (16) hve recently reported tht ACTH nd cortisone dministrtion over prolonged periods filed to increse gstric secretion in mn, nd Dvenport nd Chvre (3) filed to show ny stimulnt effects of cortisone on their in vitro preprtions of mouse stomch. The present results hve shown no evidence of ny significnt stimultion of the secretion of cid or pepsin by the infusions of ACTH, hydrocortisone or corticosterone. In order to plce in their proper physiologicl perspective the effects of the hormone infusions on gstric secretion, the very pronounced effects of intrvenous infusions of histmine hve been described longside those of the hormones. It is possible tht the hormone infusions were too short to hve cused ny gret chnges in gstric secretion, though Villrrel, Gnong, nd Gry (13) hve described increses in gstric secretion within 4 to 6 hours of ACTH dministrtion in dogs. Moreover, 5 subjects receiving ACTH-gel for 6 dys (15) showed only smll nd inconsistent chnges in gstric secretion, while 4 subjects receiving 15 mg. hydrocortisone orlly dily for 2 to 3 dys nd two others, receiving 1 mg. cortisone cette orlly dily for 4 dys showed no increse in cid or pepsin secretion in bsl gstric secretion, determined twice weekly (18). The composition of gstric juice The principl chnge in the gstric juice observed in these experiments ws decrese in

10 118 B. I. HIRSCHOWITZ, D. H. P. STREETEN, J. A. LONDON, AND H. M. POLLARD viscosity in subjects receiving ACTH or corticosterone. Hydrocortisone nd prednisolone hd no significnt effect on viscosity. These results suggest tht the effect of ACTH on viscosity ws not medited by hydrocortisone, nd my hve been medited by corticosterone or by some other hormone or contminnt. A similr decrese in viscosity hs been seen previously with more prolonged ACTH dministrtion in mn (15), nd in dogs receiving ACTH (13). In drenlectomized rts the viscosity of gstric juice is much incresed (17), nd hydrocortisone or cortisone produce decrese of stinble mucus on the surfce nd in the pits of the gstric mucos of rts (1). These results suggest n importnt but still uncler role of the drenl cortex in the regultion of gstric mucus secretion. With regrd to the concentrtion of cid, there ws no striking effect of ACTH, hydrocortisone or corticosterone. The one experiment in which ldosterone ws given showed firly steep increse in H ion concentrtion. Of ll the experiments, only the one with ldosterone hd clercut stimulnt effect on the concentrtion of pepsin in the gstric juice. While it would be unwise to drw sweeping conclusions from one experiment, the dt re striking enough to deserve considertion. We hve recently suggested (11) tht sodium depletion in rts (in the fce of drenlectomy) results in gross depression of the synthesis of gstric pepsinogen. The pprently mrked stimultion of gstric pepsin secretion by ldosterone, the most potent of the slt-retining hormones, suggests tht sodium my well ply n importnt prt in the secretion of pepsin s well s in its synthesis. It is not surprising tht mny of the effects of ACTH, notbly eosinopeni nd urinry pepsinogen increse, were reproduced by hydrocortisone, in view of the relese of prepondernce of this steroid from the humn drenl cortex stimulted by ACTH (25). On the other hnd, not ll of the effects of ACTH could be reproduced by hydrocortisone. The fll in gstric juice viscosity, for instnce, ws not observed in the hydrocorti- *sone experiments, but did occur in the corticos- -terone experiments. This observtion my hve -identified one physiologicl role for corticosterone in mn. The control nd significnce of urinry pepsinogen excretion This study hs confirmed tht ACTH invribly increses the excretion of urinry pepsinogen nd tht such increses occur within few hours of the strt of the ACTH dministrtion. It hs lso indicted tht such increses did not reflect similr chnges in gstric secretion. The evidence further shows tht the chnges observed with ACTH were the result of glucocorticoid ctivity, cting principlly, if not wholly, on the kidney. The significnt role of the glucocorticoids in the regultion of urinry pepsinogen excretion, found in these experiments, is supported by the positive correltions between urinry pepsinogen nd urinry 17-hydroxycorticoids in Addison's disese, in Cushing's syndrome, nd during ACTH stimultion (31). The mount of pepsinogen excreted in the urine depends on t lest three fctors (29). Since the stomch is the source of urinry pepsinogen, the gstric peptic cell mss (21) in prt determines whether there is none in the urine, s in pernicious nemi (32, 33) or n incresed mount s in duodenl ulcer (32, 33), nd especilly so in longstnding duodenl ulcer (22), where the gstric peptic cell mss cn resonbly be ssumed to be incresed. The second fctor involved is the secretion grdient of the peptic cells, tht is, the proportion of the peptic cell pepsinogen which is secreted into the stomch, s compred with tht pssing into the blood. We hve recently observed two cses (15, 34) in which the secretion grdient ws reversed nd lrge proportion of the gstric cell pepsinogen pssed into the blood nd so into the urine, resulting in gret increses in urinry pepsinogen, while the mount secreted into the stomch ws strikingly reduced. The resons for nd mechnisms of this reversl re not known. The third fctor involved is the renl clernce of pepsinogen from the plsm. Under both the conditions mentioned bove, the clernce of pepsinogen ws norml (29) nd the increses in urinry pepsinogen resulted directly from the elevted levels of plsm pepsinogen. On the other hnd, the increses relted to drenl glucocorticoid ctivity occurred with unchnged plsm pepsinogen levels nd little or no chnge in gstric

11 ADRENAL CORTE AND GASTRIC SECRETION pepsin secretion, nd were due entirely to increses in pepsinogen clernce by the kidney. A high level of urinry pepsinogen my therefore be found with high, low, or norml mount of gstric pepsin secretion, depending on the prticulr set of circumstnces under which it is mesured. Conversely, there my be n incresed mount of pepsin secreted into the stomch with norml, or, less commonly, decresed mount of pepsinogen excreted into the urine. The lck of correltion between gstric pepsin nd urinry pepsinogen found in this study my pper to differ strikingly from the positive correltion reported by Jnowitz nd Hollnder (32). When the norml group included in their report is exmined lone, however, there is little if ny direct correltion between urinry nd gstric pepsinogen. Their over-ll correltion coefficient is weighted by the cses with pernicious nemi t one extreme nd some of the cses with duodenl ulcers (incresed peptic cell mss) t the other extreme. SUMMARY In 49 experiments on 16 norml subjects, the effects of 8-hour intrvenous infusions of ACTH, corticosterone, hydrocortisone, ldosterone nd prednisolone on gstric secretion nd on plsm nd urine pepsinogen were compred with vlues found in the preceding 3-hour control period nd with experiments in which no hormone ws infused. The gstric effects of these hormone infusions were contrsted with 1 experiments in which histmine ws infused for 4 hours. No chnges in concentrtion or output of cid or pepsin could be ttributed unequivoclly to the hormone infusions, except for doubling of the cid nd pepsin concentrtions during the single infusion of ldosterone. The viscosity of the gstric juice ws significntly reduced by ACTH nd by corticosterone, but not by hydrocortisone, suggesting one possible role for the corticosterone which is secreted by the humn drenl. ACTH invribly incresed the output of urinry pepsinogen while the plsm pepsinogen levels remined unltered, the increses being due entirely to n incresed renl clernce of pepsinogen. These effects were reproduced by hydrocortisone nd to much smller extent by corticosterone, while ldosterone hd the opposite effect. An excellent negtive correltion between the men eosinophil count nd the mount of pepsinogen in the urine indicted tht the norml vritions of pepsinogen in the urine were probbly under control of the glucocorticoids. The resons for the lck of correltion between gstric pepsin nd urinry pepsinogen lie in the complex nd ill-understood fctors which govern the dischrge of the enzyme from the gstric cells into the blood nd in the secondry fctors which determine the mount of the enzyme clered from the blood by the kidney. ACKNOWLEDGMENTS We re grteful for the technicl ssistnce of Mrs. Esther Dullert nd Mrs. Srruth McCool. Dr. C. J. O'Donovn of the Upjohn Compny of Klmzoo, Michign, kindly supplied us with generous mounts of corticosterone, prednisolone, nd ldosterone. REFERENCES Rowntree, L. G., nd Snell, A. M., A Clinicl Study of Addison's Disese, 1st ed. Phildelphi, W. B. Sunders Co., Escmill, R. F., nd Lisser, H., Simmonds' disese. A clinicl study with review of the literture. J. Clin. Endocrinol., 1942, 2, Stempien, S. J., nd Dgrdi, A., The histmine response of the gstric mucos in ptient with drenl insufficiency: Effect of cortisone dministrtion. Gstroenterology, 1954, 27, Kyle, J., Gstric secretion in Simmonds' disese. Lncet, 1955, 2, Kyle, J., Logn, J. S., Neill, D. W., nd Welbourn, R. B., Influence of the drenl cortex on gstric secretion in mn. Lncet, 1956, 1, Engel, F. L., Addison's disese nd peptic ulcer. J. Clin. Endocrinol., 1955, 15, Tuerkischer, E., nd Wertheimer, E., Adrenlectomy nd gstric secretion. J. Endocrinol., 1945, 4, Abrms, G. D., nd Bker, B. L., The cytology nd secretory ctivity of gstric zymogenic cells fter bltion of ductless glnds. Gstroenterology, 1954, 27, Bker, B. L., nd Bridgmn, R. M., The histology of the gstro-intestinl mucos (rt) fter drenlectomy or dministrtion of drenocorticl hormones. Am. J. Ant., 1954, 94, Bker, B. L., nd Abrms, G. D., Effect of hypophysectomy on the cytology of the fundic glnds of the stomch nd on the secretion of pepsin. Am. J. Physiol., 1954, 177, 49.

12 1182 B. I. HIRSCHOWITZ, D. H. P. STREETEN, J. A. LONDON, AND H. M. POLLARD 11. Hirschowitz, B. I., Streeten, D. H. P., nd Pollrd, H. M., Influence of drenl cortex on gstric pepsinogen in the rt. Endocrinology, 1956, 59, Spiro, H. M., Reifenstein, R. W., nd Gry, S. J., The effect of drenocorticotropic hormone upon uropepsin excretion. J. Lb. & Clin. Med., 195, 35, Villrrel, R., Gnong, W., nd Gry, S. J., Effect of drenocorticotrophic hormone upon the gstric secretion of hydrochloric cid, pepsin nd electrolytes in the dog. Am. J. Physiol., 1955, 183, Zubirn, J. M., Krk, A. E., nd Drgstedt, L. R., The effect of ACTH on gstric secretion in experimentl nimls. Gstroenterology, 1952, 21, Hirschowitz, B. I., Streeten, D. H. P., Pollrd, H. M., nd Boldt, H. A., Jr., Role of gstric secretions in ctivtion of peptic ulcers by corticotropin (ACTH). J. A. M. A., 1955, 158, Kirsner, J. B., nd Ford, H., Gstric secretory stimultion: effects of phenylbutzone, histlog, ACTH, drenl steroids nd reserpine in mn. J. Lb. & Clin. Med., 1956, 48, Hirschowitz, B. I., Underhill, W. G., nd Wiggins, H. S., Gstric secretion in the rt. I. Role of sodium nd the drenl cortex, In preprtion. 18. Hirschowitz, B. I., Streeten, D. H. P., nd Pollrd, H. M., Filure to stimulte gstric secretion in mn with prolonged tretment with glucocorticoids, In preprtion. 19. Frmer, D. A., Burke, P. M., nd Smithwick, R. H., Observtions upon peptic ctivity of the gstric contents in norml individuls nd in ptients with peptic ulcertion. Surg. Forum, 1953, 4, Hwk, P. B., Oser, B. L., nd Summerson, W. H., Prcticl Physiologicl Chemistry, 12th ed. Phildelphi, The Blkiston Co., Hirschowitz, B. I., Pepsinogen in the blood. J. Lb. & Clin. Med., 1955, 46, Hirschowitz, B. I., Urinry excretion of pepsinogen in gstroduodenl ulcertion. Lncet, 1953, 1, Reddy, W. J., Jenkins, D., nd Thorn, G. W., Estimtion of 17-hydroxycorticoids in urine. Metbolism, 1952, 1, Hirschowitz, B. I., Unpublished observtions. 25. Hechter, O., nd Pincus, G., Genesis of the drenocorticl secretion. Physiol. Rev., 1954, 34, Hirschowitz, B. I., Streeten, D. H. P., London, J. A., nd Pollrd, H. M., Effects of intrvenous infusions of ACTH nd drenocorticl secretions in norml mn. II. Wter blnce, urine ph nd electrolytes, In preprtion. 27. Gry, S. J., Benson, J. A., Jr., Spiro, H. M., nd Reifenstein, R. W., Effects of ACTH nd cortisone upon the stomch: its significnce in the norml nd in peptic ulcer. Gstroenterology, 1951, 19, Gry, S. J., Benson, J. A., Jr., Reifenstein, R. W., nd Spiro, H. M., Chronic stress nd peptic ulcer. I. Effect of corticotropin (ACTH) nd cortisone on gstric secretion. J. A. M. A., 1951, 147, Hirschowitz, B. I., Significnce of incresed urinry pepsinogen (uropepsin) excretion in duodenl ulcer nd during ACTH dministrtion. J. Lb. & Clin. Med., 1956, 48, Dvenport, H. W., nd Chvre', V. J., The lck of effect of the drenl hormones upon gstric cid secretion. Endocrinology, 195, 47, Krkuer, L. J., Rmsey, C. G., nd Gry, S. J., The reltionship of gstric ctivity nd drenocorticl function: correltive study. Clin. Reserch Proc., 1955, 3, Jnowitz, H. D., nd Hollnder, F., Reltion of uropepsinogen excretion to gstric pepsin secretion in mn. J. Applied Physiol., 1951, 4, Mirsky, I. A., Block, S., Osher, S., nd Broh-Khn, R. H., Uropepsin excretion by mn. I. The source properties nd ssy of uropepsin. J. Clin. Invest., 1948, 27, Hirschowitz, B. I., Streeten, D. H., London, J. A., nd Pollrd, H. M., A steroid-induced gstric ulcer. Lncet, 1956, 2, 181.