NARRATIVE OF AN

INVESTIGATION CONCERNINGAN ANCIENT MEDICINAL REMEDYAND ITS MODERN UTILITIES

The Symphytum officinaleand its Contained Allantoin

BY

CHARLES J. MACALISTER, M.D.• F.R.C.PHem. C-U"" P1apieiDn to tM Li~l ROfIGl Southern

HoapiIiJI, to 1M ROfIGl Li"npool ChildrfM', HoapiIiJl mad10 1M Ifoor" C"". HospitGl, BourloR-or&.o...Wat...

Together with an Account of theChemical Constitution of Allantoin

BY

A. W. TITHERLEY, D.Se., Ph.D.F_l, IMt.... em Org_ic: CMJIIWtry in 1M UMwrrit,

01 Li"erpool

LONDON

JOHN BALE, SONS '" DANIELSSON, lJrn.83.91. GREAT TlTOHPIELD STREET, W.l

1936

ltr~,oJ"C'rJ by Pho'o-lilholl'.~1ry

UH

by

LEE FOUNDATION FOil NUTlllTIONAL IlESEAIlCH

MILWAUKEE " WISCONSIN

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NARRATIVE OF AN

INVESTIGATION CONCERNINGAN ANCIENT MEDICINAL REMEDYAND ITS MODERN UTILITIES

The Symphytum of/icinaleand its Contained Allantoin

BY

CHARLES ]. MACALISTER, M.D.• F.R.C.PHon. CO'IUUlting Physician to the Liverpool Royal Southem

Hospital, to the Royal Liverpool Childrlm's Hospital andto the Moore Cottage Hospital, Bourton-on·the·Water

Together with an Account of theChemical Constitution of Allantoin

BY

A. W. TITHERLEY, D.Se., Ph.D.Forrrwrly Lecturer on Organic CliB7Ilistry in the University

01 Liverpool

LONDON

JOHN BALE, SONS & DANIELSSON, LTD.83.91, GREAT TITOHFIELD STREET, W.l

1936

R,prollncrd by Photo-lithography1955· 1962

by

LEE FOUNDATION FOR NUTRITIONAL RESEARCHMILWAUKEE 3, WISCONSIN

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FOREWORD

THIS little book contains the nalTative of aninvestigation of the common Comfrey, whichled to the discovery that its roots contain

relatively large amounts of allantoin.Following this came an inquiry as to the therapeutic

uses of allantoin, which appears to be the activeprinciple to which the " virtues" attributed to theComfrey in bygone days are ascribable.

Allantoin induces cell proliferation in a physio­logical way and it is this quality that renders ituseful not only as a vulnerary but also because,as a promoter of leucocytosis, it helps to establishimmunities in some infective conditions.

Much of the earlier work was carried out manyyears ago and some of it was published in theB,'itish Medical Journal. New matter is includedin this record which has been written by way ofopening the door for further investigations by thosewho may feel interested enough to avail themselvesof clinical opportunities which, in my retirement,I do not possess,

I am indebted for much help to my colleaguesand to my professional friends, to all of whom mygrateful thanks are accorded.BOu1'ton-on-the-Water,

1936.

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SUMMARY OF CONTENTS

PAGE

ORIGIN OF THE RESEARCH I

HISTORY OF COMFREY AND OF ITS MEDICINALUSES 3

CLINICAL OBSERVATIONS WITH COMFREY II

THE CHEMICAL RESEARCH 14Chemistry of the RhizomeIdentification of Allantoin

THE CHEMICAL PHYSIOLOGY OF A1.LANTOIN 17

DISTRIBUTION OF ALLANTOIN IN THE VEGE-TABLE KINGDOM 19

EXPERIMENTS WITH PLANTS 22

CLINICAL OBSERVATIONS 26

NOTE REGARDING ALLANTOIN AND MALIG-NANCY 35

FURTHER OBSERVATIONS CONCERNING ALLAN-TOIN 40

Promotes PhagocytosisAllantoin and LeucocytosisEmployment of Allantoin in Cases of

Pneumonia and other InfectionsFurther Clinical In"7estigations Advo­

catedPREPARATION AND ADMINISTRATION OF

ALLANTOIN SOLUTION 51

NOTE REGARDING ADMINISTRATION OF THlI:PuLVERIZED CRYSTALS 62

THE CHEMICAL CONSTITUTION OF ALLANTOIN,BY DB. TITHERLEY • • 54

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2 AN ANCIENT REMEDY AND ITS MODERN UTILITIES

(left) nostril. A month later the growth had againreturned, it bulged through the incision and almostclosed the right eye. It was blue, tense, firm andlobulated, but it did not break. Further operationbeing out of the question the man was sent to hishome. About threernonths afterwards the patientwalked into Professor Thompson's study lookingin better health than he had ever seen him. Thetumour had completely disappeared from the faceand there was no trace· of it in the mouth. He hadno pain, and after having an obturator plate madeto fill the opening which was left by removal of thehard palate he went home apparently well.. He toldProfessor Thompson that he had treated it byapplying poultices of Comfrey and the swelling hadgradually disappeared. Professor Thompson said inhis paper : "I am as satisfied as can be that the growthwas malignant and of b!td type . . . I. know nothingof the effects of Comfrey root but I do not believethat it could remove· a sarcornatous tumour."

There have been one or two cases in my ownexperience where undoubtedly malignant growthsspontaneously disappeared, and the one which Ihave quoted may have been another example, butit set me thinking about t~e possibility that Comfreymight contain some substance capable of controllingor stabilizing cell-growth, and it naturally led toan investigation of the literature of Comfrey andto experiments being made with it clinically. Atthetime I had never heard of Comfrey being usedmedicinally. It was certainly not included amongthe botanical agenci~s dealt with in classes ofmateria medica when I was a student, but it becameevident from a reading of the old Herbals that itwas regarded as an important and valuable remedyin bygone days. '

HISTORICAL

COMFREY belongs to the Boraginacere Olrl>

Borage-worts. It is referred to very casuallyin the books on Materia Medica, written after

the middle of the nineteenth century. Pereira 1

(1854) says that formerly several Borage-worts wereused in medicine and he mentions among them theSymphytum oJlicinale, but he says "they possesslittle medicinal value (though formerly many virtueswere ascribed to them), and are now obsolete."

According to the Oxford English Dictionary thename Comfrey was of middle English origin and isattributed to the old French confirie or confiere,no doubt the equivalent of the modern confire­to preserve. It was also called Consolida or, insome of the English Herbals, Consound and was amember of a class oJ remedies referred to for instancein· the Pharmacopooia Londinensis Collegarum (1668)among the Radices or Roots as the Consolida orSymphytum major, and among the Herbs, Leaves andSeeds the Consolidre include, besides the Comfrey,the Consolida media (the Bugula) and the ConsolidamiminaorDaisy, also Con8olida Sara.cenia orSolidago,a variety of Comfrey having knobbed roots. Thiswas called the true Saracens' Consound or vVound­wort because it was used by the Turks and Saracensfor healing wounds. William Salmon in his EnglishHerbal (1710, page 213) classifieS it among theagglutinatives or symphitica, "which is the reasonthat 'Comfrey' is called Symphytum because ofits glewing quality." In several Herbals it is spoken

1 Pereira. "Elements of M.ateria Medica, 1854."

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4 AN ANCIENT REMEDY AND ITS MODERN UTILITIES HISTORICAL 5

of as the chief vulnerary for the same reason.Comfrey is known to English botanists as theSymphytum officinale, and be it noted that the wordSymphytum is derived from the Greek 'i,u",cfWTov," a facultate glutandi," Le. from its glueing proper­ties. The Latins used the word Consolida for thesame reason from Consolidare "to soder, close orglew up "(Salmon). Hence the English equivalentConsound often used in the Herbals.

When the Comfrey became Symphytum officinalein England I am n,ot sure. The term Officinalfirst came into use in its application to medicines,according to the Oxford Dictionary, in 1693; theLatin Officina being applied to the storeroom of aMonastery in which Medicines, etc., were kept, andso herbs, plants, drugs, etc., kept in stock in anApothecary's shop became" Officinal" or as beingof recognized utility. Comfrey was never introducedinto the British Pharmacopooia but it is describedin Squire's Companion to the British Pharmacopooia(17th edition, page 619) as having astringent, muci­laginous and glutinous properties. Its authorknew a bone-setter who had rendered himselffamous by treating fractures with a pulp made of thescraped root spread to the thickness of a crownpiece upon cambric or old muslin which was wrappedround the limb and bandaged over. It soon stif­fened, giving great strength and support to the part,and the bandage was not removed until the limbwas well.

Squire mentions that Comfrey was officiallyrecognized in the following Pharmacopooias: InBelgium as Radix symphyt'i; France Consonde;Mexico Sinfito; Portugal Consolida major; SpainSinfito major; and in no others.

There are three varieties of Comfrey referred toin the Herbals: (1) The Symphitum majus vulgare

or Common Great Comfrey; (2) the Symphitummajus flare purpureo-the Great Comfrey withpurple flowers; (3) the Symphitum tuberosum orComfrey with knobbed roots, which is the SaracenConsound formerly mentioned. This latter hasseveral species and was probably selected on accountof the largeness of its roots. All the varieties wereused, however, the roots being gathered during thewinter months (October to March). The leaves, alsoemployed, were gathered in June and July duringand after inflorescence.

The medical chronology of the plant is interestingon account of its antiquity. In the new EnglishDictionary, Saxon Leechdom is quoted (c. 1000),"This Wort strengthens the man," and it states," Ad fluxum Sanguinis accipe de Confirma, hoc estconsolida." In the Saxon Herbarium it was thusrecommended for one" Bursten Within"; the leaveswere roasted in hot ashes and mixed with honeyand then taken fasting. There are many referencesto Comfrey, and I cannot do better than quote somedetails of its history from a paper by the late ProfessorR. J. Harvey Gibsonl which gives a very goodhistorical summary. He says: "In Sarracenius'sversion of Dioscorides, published in 1596, descriptionsare given of two species of Symphytum; Chap. IX(Liber II) is headed' De symphyto petraeo, , andChap. X 'De Symphyto Altero.' The' roots'and their 'vertues' are described in the followingterms: 'Radices demittuntur foris nigrre, intusc'andidre, glutinosre, quarum etiam est usus. Tritreet potre sanguinem excreantibus ruptisque proficiulltet recentia vulnera impositre glutinant; carnumquoque frusta quibuscum conjunguntur COgUllt

1 Note on the Anatomy and Herbal History of Symphytumofficinale by R. J. Harvey Gibson, M.A., F.Z.S., Prof. of Botany,University of Liverpool, Pharmaceutical Journ. and Pharmacist,Jan. 27, 1912.

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6 AN ANCIENT REMEDY A~D ITS MODERN UTILITIES HISTORICAL 7

ita ut coalescant. Clllterum inflammationibus,prresertimque sedis, cum Senecionis follis utiliterillinuntur.' "

Bock, in his work, "De stirpium" (Kyber'sedition, 1552), quotes and expands this sentencefrom Dioscorides, and describes the then recognizedmethods of application of the plant, internallyand externally. Fuchs also (1542) quotes thesame extract, and also the views of Galen andPliny, which are -practically in t~e phraseology ofDioscorides.

In W. Turner's" Herball" (1568) the followingoccurs: "Of Comfrey Symphytum. The rootesare good if they be broken and dronken for themthat spitte blood, and are bursten. The same, laydto, are good to glewe together freshe woundes.They are also good to be layd to inflammation, andspecially of the fundament, with the leaves ofgroundsell." This account is also merely a condensedtranslation of Dioscorides.

Dodoens, in his "Cruydtboeck," translated byLyte (1578), expands Turner's statement, addingthat when " mengled with sugar, syropes, or honny. . . are good to be layde upon all hoate tumours."Quite similar statements as to the. value of l;omfreyrhizome are made in Bulleyn's "Herbal" (1562)and in the" Adversaria" of Penaand Lobelius (1570),and the "Stirpium Historia" of the latter author(l576), also in the epitome of Camerarius (1586).J. Bauhin (" Historia," 1651) expresses his concur­rence in the views of the sixteenth century herbalistsas to the curative value of decoctions of Comfreyin all cases of wounds, blood-spitting, or even brokenlimbs.

Gerard's" Herball " (1597) repeats, but at some­what greater length, the same account. He assertsthe efficacy of Comfrey also in healing up "ulcers

of the lunges" and " ulcers of the kidneies, thoughthey have been of long continuance." Parkinson(" Theatrum Botanicum," 1640) gives the samegeneral description of the "vertues" of Comfrey,but adds: "The rootes of Comfrey, taken fresh,beaten small, spread upon leather, and laid uponany place troubled with the gout, doe presentlygive ease of the paines; and applyed in the samemanner, giveth ease to pained joynts, and profitethvery much for running and moist ulcers, gangrenes,mortifications, and the like." There is a marblestatue of John Parkinson (born 1567), Apothecaryto King James I, outside the Palm House, SeftonPark, Liverpool.

In the "Compleat Herbal" of Tournefort (171 U)a long account is given of the" vertues " of Comfreyand of its general characters. It is interesting thatthis author states that "upon a chymical analysisthe Comfrey yields many acid liquids, much earth,very little sulphur and no concreted volatile saltbut a small quantity of a urinous spirit and avery moderate quantity of fixed salts." Tournefortcloses his account with the observations ofHieronymus Rensuerus "that a charlatan cureda certain person of a malignant ulcer, pronouncedto be a cancer by the surgeons, and left by them asincurable, by applying twice a day the root ofComfrey bruised, having first peeled off the externalblackish bark or rind; but the cancer was not ofabove eight or ten weeks standing."

By the end of the eighteenth century Comfreyseems to have declined in popularity amongphysicians; thus Woodville (" Medical Botany,"1794) writes: "A supposed vulnerary efficacy,for which this plant was formerly in great repute,and to which it seems to owe its name" (Comfrey= confirma), " will now be considered as nothing in

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8 AN ANCIENT REMEDY AND ITS MODERN UTILITIES HISTORICAL 9

its recommendation." He adds: "The mucila­ginous matter is the only medicinal principle, andmay be used as an emollient and demulcent."

There are many other references to Comfrey whichall tell the same story, and it is unnecessary toelaborate the evidence that it was at one time heldin high repute by the medical profession. Aninteresting point is the fact that in countrv districtsit is still valued by agricultural and oth~r workers011 account of its curative properties. When visitinga farm at Tarvin in Cheshire many years ago, Iwas interested to find that its owner always kept abed of Comfrey in order that he might providevillagers with it when occasions arose. Dr. WalterMoore, of Bourton-on-the-Water, has recentlyinformed me that, within his recollection, plotsof it were grown as a food for cattle, on accountof its reputation for producing milk, rich both inquality and quantity. Another interesting Glouces­tershire reference is contained in a letter publishedby Mr. Edwin Green of Cheltenham! in 1912 inwhich he wrote that in Gloucestershire this plantwhen cooked in the same way as spinach is usedvery largely by inany people during the spring.He stated that it is well known there as a bloodpurifier not only. for human beings but also forcattle and horses, the effect on the latter being toproduce a wonderful glossy coat. He knew agentleman near Cheltenham who had a field of4 acres in which nothing but this plant was grown.He gave it not only to his horses but was neverwithouta dish Of it, when in season, instead of spinach.

One more point before leaving the history of thisinteresting plant. Dr. Edward Nicholson, of Neuilly(Seine), who furnished numerous references when Iwas first working on this subject, stated in one of

1 Daily Mail, :lIarch '27, 191'2.

his letters (Nov. 15, 1911): "I am quite at onewith you in the examination of forgotten 'Worts.'Certainly until the manufacture of the new class ofsynthetic medicines prevailed, one could counton one's fingers medicines that had not been dis­covered by old women or savages, and now onefinds that some of these synthetic remedies arescientific imitations (however unconsciously) ofthe 'principles' contained of the old Herbals."

No doubt in the past, as in the present, theintroduction of new methods of treatment led to thedisuse of old ones. Fashions in medicines changedthEm as now, and many really valuable naturalremedies belonging to the periods of rational empiri­cism were left behind and forgotten or relegated tothe limbo of lost reputations.

I myself have heard Comfrey spoken of as all" old woman's remedy," and I admit it in the sensethat it probably dates from the time when womanwas the Priestess of Medicine. I referred to thisin a paper on "The Psychology of Nursing," writtenfor the Cripples Journal in 1928, in which I statedthat "Nursing is a profession which pre-eminentlybelongs to woman, and the psychology of the nurseis essentially that of woman, who throughout theages has been regarded as the possessor of inborngifts and attributes which render her the naturaltender of the weak and sick and of the maimed andhurt ... tilis is related to the maternal instinctswhich are present, although they may be dormantin a greater or lesser degree, in every woman;instincts concerned not only with the propagationof the race but with its preservation. The exper­iences which woman acquired in prehistoric timesregarding the care of her offspring during childhoodand beyond was probably associated with someknowledge which would be handed on from mother

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10 AN ANCIENT REMEDY AND ITS MODERN UTILITIES

to daughter. So it would happen that adultsappealed to woman as to a mother when smittenwith illness." She was the Witch or Wise Womanof those days-and it is within the realms ofpossibility that Comfrey was among the "simples"employed by her, and may truly be called an old orancient" woman's remedy."

Some idea of the traditional therapeutic virtuesof Comfrey may be gathered from the names bywhich it was popularly known. For instanceKnitbacke (Gerrard 1597), Comfort Knitbene(Scotland). In Aberdeen it was called ComferKnitbeen, and a preparation made by boiling theroot in oil or lard was extolled by old womenfor hardening and strengthening fractures. Thisproperty also accounted for its being called Bone-setor Knit Bone in Lancashire. It appears to havebeen used both internally and externally in fracturesin all districts.

A rather amusing letter received from a doctor inLancashire in 1912 illustrates the faith of the peoplein Comfrey as a healer. He wrote: "Three yearsago I was called to see a girl with gastric ulcer,hrematemesis and severe vOIniting and treated thecase in the usual orthodox manner. In three weeksthe patient was able to return to the mill. Whencongratulating the mother on her daughter's speedyrecoverv the old woman said to me :

" 'D~ you mind my telling you somethingDoctor l' On my replying in the negative--

" , Well,' she said, 'my girl has never had a dropof your medicine and all she has supped is pints ofstrong Comfrey tea.'

"Since this occasion I have found it an excellentsedative for the gastric mucous membrane."

CLINICAL OBSERVATIONS WITHCOMFREY

H AVING become acquainted with the historyof the plant and the kinds of maladies forthe treatment of which preparations made from

it had been employed, the next procedure was totry it out and discover whether it possessed anyof the therapeutic properties ascribed to it. ProfessorHarvey Gibson had obtained a large quantity ofthe ground and unground rhizome, some of whichwas handed to Dr. Titherley, then head of theOrganic Chemistry Department, University of Liver­pool, and Mr. Norman Coppin, who was working inthe laboratory of Professor Benjamin Moore (Bio­chemistry), and while they were making a carefulchemical investigation of it, which took a consider­able time, I proceeded to dreSB the only ulcer whichwas then available with a strong infusion made fromthe powdered root.

This case was an exceedingly unprol11lsmg onebecause it was a "rodent" of about two years'duration, not a simple ulcer.

The patient was a woman aged 87, and it seemeda suitable case for observation following the historyof the malignant growth recorded by ProfessorThompson which originated this research.

It was a stroke of fortune that this case was thefirst one to be experimented upon because, havingresisted all kinds of previous treatment, the markedepithelial growth which took place upon it seemedmore likely to be the result of a specific action of theapplication than would have been the case in anordinary varicose ulcer for instance.

2

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12 AN ANCIEKT REMEDY AND ITS MODERN UTILITIES CLINICAL,OBSERVATIONS WITH COMFREY 13

It was a very large ulcer (measuring 4 by 3 inches)involving the skin and deeper structures over theupper thorax and it was slowly spreading, moreespecially by its upper margin which was high andundermined; the other margins were less raised.The base was irregular and there was some sero­purulent, discharge. Mter being dressed with themucilaginous infusion for about a week the surfacecleaned and a distinct ingrowth of epithelium couldbe seen taking place from some of the marginalpoints. Later on the upper margin flattenedsomewhat on its inner aspect, the underminingvanished, and after growing here and breaking downthere for a time the epithelium became strongerand closed in to a considerable extent.

By this time-Dr. Titherley reported to me that hehad obtained a definite, so-far unidentified, crystal­line body from the root and he was able to give mesufficient of this to experiment with. Since it wasvery sparingly soluble in water, quite a large amountof solution was made which was now used as adressing for the ulcer instead of the infusion. Withthis application the skinning over process took placemore rapidly and in the course of a month was allbut completed. Unfortunately the taking of aphotograph was put off in the hope of getting apicture of the completely covered ulcer.

It was never obtained however because throughthe perverseness of fortune the aged patient con­tracted influenza, which was epidemic in the Institu­tion at the time and she died of bronchitis. As amatter of fact this was the only ulcer initiallytreated with the infusion of Comfrey root alone, andthe fact that epithelial growth was further hastenedafter dressing it with a solution of the crystallinebody suggested that this might be the active prin-ciple which promoted healing. .

That infusions of the root are very active, however,was indicated by descriptions of cases treated withit which came from a variety of sources. One ofthe most striking was published in the BritishMedical Jou1-nal of June 8, 1912, by Dr. CharlesSearle of Cambridge. The case had the followinghistory;-

The patient was a man aged 83, first seen onOctober 23, 1911. He suffered from shortness ofbreath, and swelling of the legs on which were someulcers due to neglect. For some months his conditionwas very grave; he had marked arteriosclerosis, aloud aortic systolic murmur, with a feeble pulseand low temperature. The urine contained blood,albumin, and casts, but no sugar.

During December, 1911, a fungating ulcer appearedon the dorsum of the left foot. It rapidly spread,and eventually exposed the metatarsal bones. InJanuary, 1912, the patient's condition appearedto be hopeless, he became at times delirious, andwas removed home to die. He was then treatedwith four-hourly fomentations made with decoctionof Comfrey root. The ulcer immediately began tofill up rapidly and was practically healed by the endof April, and the patient's condition made corres­ponding improvement.

Several medical men were kind enough to confirmmy observations from their own experiences withinfusions of Comfrey for the treatment of ulcers,but further reference to this must be deferred untilI Gome to speak of allantoin which proved to be theactual crystalline body extracted from the root.

I must state at this point that neither Comfreynor its constituent is a specific for rodent ulcers.The case of rodent ulcer recorded which raisedconsiderable hopes, naturally led to others beingsimilarly dealt with, but without convincing results.

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THE CHEMICAL RESEARCH 15

made allantoin and from that obtained from theroot; their melting points were the same, and soforth.

Allantoin (C,HoN,03) is a compound which isobtained by the alkaline oxidation of uric acid in thecold.

It is a white crystalline substance, melting atabout 2260 C., with decomposition. It is onlyslightly soluble in cold water (0,6 per cent.), butreadily in hot water. It is rather more soluble incold alcohol, but it is quite insoluble in ether. Dryallantoin is quite stable, but if boiled with waterfor a considerable time it undoubtedly undergoesdecomposition to some extent. It is decomposedby alkali, giving a variety of products, the natureof which entirely depend upon the conditions underwhich the experiment is carried out. It willbe seen from Dr. Titherley's description of thechemical constitution of allantoin (p. 54) thathe gives it two distinct chemical formulre: one asingle five-atom ring (mono-cyciic) with ureide sidechain, the other a double (bi-cyclic) five-atom ringconstitution without side chain, and he shows thatone form passes into the other by the mere wanderingof a hydrogen atom. Quoting his words from a letterMay 3, 1933, descriptive of these peculiarities hesays: "One of these forms (the double cyclic one)I call pselldo-allantoin, and I think, though it hasnever been proved, that it is soluble in water. At allevents in one of the synthetic experiments I got asoluble form which on standing passes over intothe ordinary familiar crystals. This soluble form

THE CHEMICAL RESEARCH

BEFORE proceeding to describe the clinicaland other observations which led to theconclusion that allantoin has to do with

cell growth, it may be as well to give a short accountof the result of the analysis whereby this substancewas isolated from Comfrey, and of some of itschemical oharacteristics. In his preliminary exam­ination Dr. Titherley established the facts thatthe root contained :-

(I) Gums.(2) Sugars, including a reducing sugar.(3) Resins.(4) A protocatechuic derivative or derivatives.(5) A substance giving an intense yellow solution

with sodium hydrate (not investigated further).(6) A crystalline solid, which was isolated in a

pure condition. It was very rich in nitrogen andmelted at 2260 C. Since from clinical observationsthis latter body appeared to be the physiologicallyactive constituent of the root, Mr. Coppin wasasked to devote his attention to its investigation.Ultimately Dr. Titherley and he found that the rootcontained about 0·8 per cent. of this crystallinesubstance, and by accurate determination of itscarbon, hydrogen, and nitrogen contents showedthat it possessed the same empirical formula asallantoin, which it greatly resembled in its chemicalproperties.

Au.ANTOIN

Some allantoin was now prepared from uric acid,and the product from the root was proved con­clusively to be an identical substance by chemicalmethods. For example, allantoic acid and otherderivatives were prepared both from the chemically

CO-NH

/NH-l doco....... \I I

NH-C-NHUric acid

NHa

.......NH-CO doco I I

.......NH-CH-NHAllanmn

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16 AN ANCIENT REMEDY AND ITS MODERN UTILITIES

is too unstable to keep. I mention these facts toillustrate what I mean by saying that allantoinis a peculiar substance, and I believe that Naturesomehow utilizes those peculiarities in cell meta­bolism."

It may be well at this point to refer to the factthat when carrying out some experiments concerningthe action of allantoin on leucocytes during twoperiods separated by an interval of several years,I got such a diversity of results that I wrote toDr. Titherley in 1933 suggesting a possible instabilityin the allantoin crystals which might be broughtabout by gradual decomposition. I was led to sus­pect this because the diversity disappeared on usingfreshly prepared crystals. In his reply Dr. Titherleyreferred to the tautomeric properties of the substance,and its peculiarity in undergoing the changes inchemical constitution, above referred to, probablydue to this tautomerism. He did not think itshould alter its therapeutic behaviour, however,since an equilibrium would be set up between thetwo forms in solution, but he considered it con­ceivable that this equilibrium is only slowly obtainedby pure water, and perhaps more quickly if a traceof alkali or acid is present. He knew nothing onthis point about allantoin, but it certainly occursin other organic tautomeric compounds wherethe rate of attainment in equilibrium solution isenormously dependent on traces of other substanceswhich accelerate the change by catalysis.

This is more or less by the way, but it has beenthought well to mention it as pointing to the neces­sity for dissolving the crystals in distilled water.This precaution was observed in the first (original)set of experiments, but in the later one which gavesuch different results tap water was almost certainlyused by an independent observer.

THE CHEMICAL PHYSIOLOGY OFALLANTOIN

REGARDING the chemical physiology of allan­toin, or the part which it plays in humanmetabolism, very little is known, but some

interesting facts have been recorded which maythrow light upon its action as a cell-proliferant,and may point to its having a function to performin the bodily chemistry apart from any possibilityof its being""a product of purine metabolism, in whichlight it has generally been regarded. It is presentboth in animals and in plants. It was first dis­covered in the former, and received its name fromthe fact that it was found in the fretal allantoicfluid. Later on it was identified in the urine ofpregnant women. Its presence has been demon­strated in very small amounts as a normal constit.uentof the urines of healthy people; but that it is notan end-product of human metabolism-which meansthat it is probably not derived from the oxidationof uric acid, to which it is closely allied-has beenshown by a good many observers, as pointed outby Dr. Ackroyd in a paper published in the Bio­chemical Journal for March, 1911. This is animportant observation, and is based upon the worksof Schittenhelm, Wiener, Minkowski, Poduschka, and\Viechowski, who have shown that when allantoinis given to man it can be recovered to a consi.derableextent in the urine; and the author himself con­cludes "that the whole quantity of allantoinexcreted by man on a milk and vegetable diet maybe d~riveddirectly from that contained in the food.~'

You will note that I am speaking of the relation of

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18 AN ANCIENT REMEDY AND ITS MODERN UTILITIES

allantoin to human metabolism only. In the dog,cat and rabbit it appears to be a normal end-productof metabolism, and experiments made upon themseem to show that the giving of foods rich in purines,such as thYmus and pancreas, gives rise in the twoformer animals to increased allantoin elimination;and in the latter animal the addition of sodiumnucleate alone and sodium nucleate together withuric acid to the fodder, resulted in almost all thepurine products being excreted in the allantoicfraction of the urine.1 Furthermore, the sameobserver noted that the intravenous injection ofnucleic acid caused an increase only in purine basesand allantoin, and that the ingestion of allantoinitself caused in these animals a marked increase inthe total nitrogen excreted; the allantoin excretedbeing nearly double the amount that was ingested.The difference between the metabolism of theseanimals and that ofman is well shownby Wiechowski,who found that, given subcutaneously, uric acidappears mostly as allantoin in the urines of the dogand rabbit, whereas in human urine about 90 percent. is excreted unaltered.2

If these facts are reliable, the allantoin in humanurine is mainly derived from vegetable foods andfrom milk, which Dr. Ackroyd found to contain about0'019 grm. per litre, and in the healthy individualit appears to pass practically unchanged throughthe economy, the amount eliminated representingthe amount which had been ingested.

In this relation, however, its tautomeric qualitiesand the influences of catalysis already referred toshould be remembered.

1 Schittenhelm and Seisser, Zeitschr. E;;pt. Path. Ther., 1909,vii, 116-133.

2 Wiechowski, Biochcm. Zeitschr., 1910, xxv, 431-459.

DISTRIBUTION OF ALLANTOIN INTHE VEGETABLE KINGDOM

OUR knowledge of this is not very extensivebut it is a very suggestive fact that suchanalyses as have been made indicate that

it is generally found in parts which are related togrowth, either active or potential. We have a strikingexample of this in the Comfrey where it is presentin the roots and terminal buds. The leaves havenot yet been thoroughly investigated, but theinteresting point is the large amount of allantoinin the rhizome, greater than in any plants heretoforeinvestigated. E. Schulze and J. Barbieri 1 in 1881-82found it in the buds of certain plants and in thebark of branches of trees and Ackroyd refers to~ts identification by Richardson Crampton (1886)m the embryos of wheat separated in the processof milling and in beet juice. Ackroyd2 himselfdemonstrated its presence in bread, french beans andgreen peas, whereas it is absent in bananas andrhubarb. This regional location of allantoin inp~ants is interesting when regarded in conjunctionWIth the fact that it is a characteristic componentof the fretal allantoic secretion, and related thereforeto an important structure connected with thefretal circulation, a structure along which thevessels pass which convey the fretal blood to andfrom its intimate relationship with the maternalblood.

Whenever we find any substances constantly incertain parts of plants or animals, it is quite reason­able to suppose that they may be in some way related

1 Journ. of Prak. Chern. [2] xxv, 147.2 Biocllelll. journ., v, 403.

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20 AN ANCIENT REMEDY AND ITS MODERN UTILITIES ALLANTOIN IN THE VEGETABLE KINGDOM 21

to and necessary for the particular tissues whichhave selected them; and although the allantoinin the human embryo might be regarded as a fretalwaste product, I think we may feel justified inassuming that, in the economics of Nature, it hasa function to perform, perhaps in relation to cell­multiplication, especially as it is not at onceeliminated through the maternal circulation, and thesame suggestion comes from the fact that it is alsopresent in milk, the food of the rapidly growingyoung organism, and in those parts of some plantsin which active cell-multiplication takes place.

Bearing on this comes a very interesting analogybetween the presence of allantoin in the fretalallantois and in the root of the Comfrey plant.In the earliest months of pregnancy, dating' fromthe third week onwards, the allantois becomesrelatively large, and the amount of allantoin con­tained in it corresponds to some extent with thesize of the sack. The vessels of the chorion convey­ing the maternal blood to the fretus pass throughthe allantois and probably derive the allantoin fromit, to be utilized in the metabolism connected withgrowth and development. As pregnancy advancesthe allantois diminishes in size and at length, shortlybefore the child is born, it becomes vestigial andthe amount of allantoin infinitesimal. Comparethis with the Comfrey rhizome which in the earliestmonths of the year (January to March) containsfrom 0'6 to 0'8 per cent. of allantoin. Analysed acouple of months later it contains about 0'4 percent. In July the amount is still further dimin­ished and when the plant is in full growth practicallynone is to be found in the rhizome but it is dis­coverable in the terminal buds, leaves, and youngshoots. This important fact may be regarded asevidence that the plant withdraws a.llantoin from

its storehouse in the rhizome and utilizes it forpurposes of cell-proliferation. In continuation ofthe analogy above referred to it is interesting thatthe maternal milk contains about 0·006 per cent. ofallantoin, a fact that may have something to do withthe further growth of the child after birth.

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EXPERIMENTS WITH PLANTS 23

EXPERIMENTS WITH PLANTS

THE presence of allantoin in the undergroundreserves and growing parts of plants, aswell as its relation to the footus in the allantois

and in milk-the food of the rapidly growing infant-added to the clinical evidence that it promoteshealing in ulcerative conditions which will bereferred to later, naturally led to the suggestion thatexperiments made upon plants might ~fford so~e

information, confirmatory or otherwIse, of Itsproliferative properties or functions. By my requestMr. Coppin planted a large number of hy~cinthbulbs (the growth of which had been started 'ill thedark) in solutions of allantoin varying from 0·1 to0·5 per cent., and it was found that the gro~h ofthe roots was inhibited in a ratio proportIonateto the amount of allantoin in the solution-that is,the stronger the solution the less was the amount ofgrowth in the ro.ot. . ...

Notwithstanding this diminished root growth,which was confirmed by microscopic examination,the flower stems of the plants grew in a stuntedway, but none had blossomed at the end of twel~eweeks, and it therefore appeared that allantOIDdid not promote cell-growth when added to thewater in which the bulbs were growing, in facttheir growth appeared to be retarded. This wasdisappointing, but an interesting development nowensued. It seemed certain that in plants theallantoin or other proliferative agent is stored foruse in the rhizomes, buds, barks and germinal parts,and is probably elaborated there ~s the result ?fsome metabolic process. There IS no allantOIDnormaUy in the water or earth in which bulbs are

grown, but it or some kindred substance is evidentlyformed and stored in the bulb or, in the case of otherplants, in the rhizomes or roots, to be drawn upon asrequired for advancing the procef?ses of growth anddevelopment. This being the case, the suggestionnaturally arose that one might try the effect ofinjecting a solution of allantoin into the bulbs, anda number of expe~ents were conducted on theselines, the first of whlch was made in a more or lesscasual way as follows :-

A child in the Liverpool Royal Southern Hospitalhad two earth-grown hyacinths in a pot. They hadgrown quite unequally, one having developed wellwith the commencement of a flower, the other beingfeeble, short and showing no signs of blossom.

About 15 minims of allantoin solution (0'4 percent.) were injected on several occasions into thebulb of the latter, with the result that rapid growthensued and it overgrew its more vigorous neighbour,and flowered before it (fig. 1).

This experiment ~xcited the interest of the Sisterof the ward (Miss Archer) and of the Matron (MissJolly), and they gave similar injections into thebulbs of a considerable number of plants in aboutequal stages of growth. Controls were used, somebeing injected with quantities of water equal inamount to the quantities of allantoin solution given,others being grown without any injections; theseexperiments were conducted in earth-grown bulbs.In addition, some hyacinth bulbs which had juststarted growth, the shoots being about lin. high,'were planted in water, and some of them wereinjected every third or fourth day with allantoinsolution, some with water only, the remainder beingcontrols, and the same results were obtained inevery case. The allantoin evidently acted as acell-proliferant, forcing the growth of the shoots,

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24 AX ANCIENT REMEDY AND ITS MODERK UTILITIES

and especially of the flowers (for it was noticeablethat the plant often blossomed with comparativelylittle leaf-growth), commonly before their untreatedneighbours had reached anything like the stage offlower production. The water-injected plants grewbetter than the uninjected ones, but nothing like sorapidly as those to which allantoin had been added.

These experiments were repeated many times withtulips (figs. 2, 3 and 4), lilies of the valley and otherplants, care being taken to ensure that they wereplanted at the same time, in the same tubful ofearth, and under the same conditions of temperatureand surroundings. These results have been con­firmed many times, and in the cases of non-bulbousplants the injection of allantoin solution into orbelow the flower-buds or into the bases of individualspikes haR resulted in the production of large flowerscontrasting strongly with other untrsated flowers orspikes on the same plant (figs. 5 and 6).

In the water-grown plants which were injected itwas noted that with the increased growth of theshoots there was Bometimes a diminished growth ofthe roots, which were considerably longer andstronger in the controls.

This led to the impre sion that perhaps the rootBwere not so necessary to the plant if its water aswell as the proliferant content were kept high,and in order to test this point a number of hyacinthbulbs were selected which had shoots ! in. highbut no visible roots. Some of these were injectedwith allantoin solution, some with water, othersbeing uninjected, and they were simply placed upona plate without earth or water. At the end of sevenor eight days the little shoots of the treated plantswere opening out into leaves. The water-injectedbulbs also lived, but did not grow so well, whereasthe shoots of the controls browned at the tips and

FIG. I.

Hyacillths.-The one on the left was injected withallalltoill. It was less iu height and feebler than itsneighbour on the rigbt at the commencement of tbeexperiment.

FIG. 2.

A bowl of tlilips.-A central lille of the bulbs wereinjected with allantoill. Tho m:\T~in&1 OliOS wore notinjected. Figs. '.!, 3 alld 4 show tho stages in growthin the two sots.

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)<'1G.3.

FIG. 4.

FIG. 5.

Chrysanthemum which was injected on several occasionsat the base of the spike of flowers on the left. Showing theadvanced inflorescence compared with the portions of theplant which are undergoing normal growth.

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EXPERL1IfENTS WITH PLAXT 2r>

FIG. G.

In t,his chrysanthemum the injections were given into theflower bud of the large bloom when it was a.t the stage of theunexpanded flower on the right. There was no nipping ofthe young flower buds to promote la.rge blooms.

shrivelled up. ~ot a sign of roots made theirappearance in any of these plants.

From these experiments one gathers the impressionthat allantoin is a substance which is capable ofbeing utilized by vegetable cells in connection withtheir proliferative processes, just as there seems to beproof that it has proliferative properties in connectionwith certain animal cells, if one may judge bythe way in which it promotes healing in chronicand acute ulcerative conditions which will bereferred to later on. In both cases the reproducedcells are normal microscopically and resemble thosefrom which they took their origin.

In connection with the injection of bulbs a medicalman wrote to me many years ago explaining thatin repeating my experiments his results were con­tradictory to those which I had obtained. Hisplants became stunted and growth was interferedwith. On I1sking for details concernin&. his experi­ment it transpired that he had injecM"d his bulbswith an infusion of Comfrey which he had preparedby prolonged boiling of the roots. It is qui~

probable that the contained allantoin would bedecomposed by the boiling, but there is also apossibility that in the root there may be a controllingsubstance uninfluenced by hel1t which retardsgrowth. A research concerning this possibilitywas not proceeded with.

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CLINICAL OBSERVATIONS 27

CLINICAL OBSERVATIONS

THE original clinicp,L observations made withallantoin were chiefly conducted in casesof superficial ulcers of various kinds, in order

that the effects on the growth of epithelium mightbe carefully watched. In the selection of cases,great care was exercised. in order to make certainthat other conditions which would ordinarily promotehealing were not alone operating and bringing aboutor starting cell-proliferation. On this account anendeavour was made to safeguard observationsin the first place by dealing only with those ulcerswhich had refused to heal unde" ordinary conditionsof rest and cleanliness, together with other forms oftreatment, and in the second place a good manymedical men were provided with fresh solutions ofallantoin wherewith to trert their cases in orderthat our own results might be confirmed or temperedby theirs. One is rather apt, when experimentingwith a substance in this way, try allow optimism toexaggerate the resultant benefits, and it is anadvantage to get others to form ind.ependent judg­ments concerning them from their own observations.

After publishing some of these results, numerousapplications for supplies of allantoin came frommedical men, not only in this country but also fromCanada and other Dominions, wherewith to treatcases under their immediate care, and many of themwere good enough to record their results, some ofwhich, being of great interest, will be referred to.

I was very fortunate in having surgical colleagueswho were interested in this research, and numerouscases were placed at my disposal in the wards of thehOtipitals.

A striking case was that of a woman, aged 48,who was transferred to me by Mr. Douglas Crawfordon July 20, 1911. .There was a large ulcer on thedorsum of the foot and another, practically con­tinuous with it, over the lower third of the leg.The bases were in places sloughy and even gangrenouslooking, and there was a purulent discharge. Shewas sent to Mr. Crawford, I understood, for hisopinion as to whether the leg should be amputated.The ulcer measured 5 in. by 4 in., and had been inexistence for five years. Allantoin dressings werecommenced on July 25. A week later the surfacehad cleaned and presented healthy granulations, anda rapid growth of epithelium was taking place fromall the margins. On August 12 it was manifestlyhealing, and on August 17, i.e., in twenty-threedays, this huge ulcer was reduced to the size of apin's head. The scar was healthy and sound. Thepatient was kept in bed for a fortnight, and afterher discharge it remained sound and well.

Another class of ulcer which quickly respondedto allantoin includes those which are apt to occurin paralytic cases. We had an example of this in.a girl, aged 11 years, who had a large ulcer on thedorsum of her left foot. The skin had broken downrapidly, leaving a deep circular ulcer about thesize of a penny.

Since it showed no signs of healing at the end offive weeks the late Sir Robert Jones invited meto dress it with allantoin. This treatment com­menced on March 10, 1911. The epithelium rapidlygrew in, and in four weeks it was entirely healed.

Another case referred by Sir Robert Jones wasthat of a young woman who had circular paralyticulcers on each leg. These were examples of whatused to be called weak ulcers in my student days,and they had remained practically unchanged, one

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28 AN ANCIENT REMEDY AND ITS MODERN UTILITIES CLINICAL OBSERVATIONS 29

of them for five months and the other for eightmonths, in spite of the fact that the patient hadbeen recumbent for several weeks. On May 2they were dressed with allantoin; on the 17th theulcer on the right leg was skinned over and thoseon the left one healed soon afterwards. The epi­thelial coverings in this case were thin, and thecicatrices soft and flat. She was one of thosepatients with flail legs, the surface cold and musclesatonic, and one was not surprised to hear that oneof the ulcers subsequently recurred.

I might quote many cases of various kinds whichclearly confirmed the cell-proliferative qualities ofallantoin. Among these were several cases ofvaricose ulcers, but it was found that burns andscalds of the lesser degrees were very useful fieldsfor observation. This was because islets of epithe­lium, many of them at first invisible to the nakedeye, formed centres from which new epithelialgrowths could be seen spreading from day to daywith remarkable rapidity. In a letter to theBritish Medical Journal (January 13, 1912) Mr.R. W. Murray (Hon. Surgeon Liverpool NorthernHospital) confirmed the value of allantoin as acell-proliferant as follows: "I can confirm Dr.Macalister's remarks upon the value of allantoinas a cell proliferant. Towards the end of last year.there was an explosion at works in the neighbour­hood of the hospital and we were -called upon totreat a large number of men who were severelyburnt on the hands, forearms, and face. The burnswere mostly of the second or third degree, and forabout a week they were dressed with gauze soakedeither in a solution of picric acid or in a solution ofiodine.

" Dr. Macalister asked me to try dressing themwith allantoin, and kindly provided us with a

quantity of it. In the first instance it was triedon two or three cases only, but the results were sosatisfactory and so convincing to house-surgeons,dressers, and nurses, that dressing with allantoinsolution soon became general. It not only stimu­lates epithelial growth, but' cleans up' sloughingsurfaces in a most remarkable fashion. Whennurses and house-surgeons are really keen aboutany particular line of treatment there is generallysomething in it. This has certainly been ourexperience with allantoin."

Mr. Murray's statement that allantoin cleans upsloughing surfaces applies not only to burns but toulcers generally, and the question arose as to whetherit possessed any antiseptic properties. Thisc1eaning­up process is of course essential if healing is tooccur, because healthy cell-proliferation will nottake place over septic surfaces, and it was essentialto determine whether the allantoin was primarilydestructive to micro-organism or promoted thiseffect by establishing physiological conditions in thecells and their surroundings which rendered themimmune to micro-organisms. Some simple experi­ments had previously demonstrated that, far frombeing a poisonous antiseptic, it possesses no toxicqualities, and rather favours than inhibits culturegrowths of organisms. In August, 1911, during acruise to the Shetlands in the late Professor SirWilliam Herdman's yacht" The Runa," I was ableto make a number of observations concerning theeffects which followed the placing of samples of theplankton gatherings (which were constantly avail­able during tow-netting operations) in sea-watercontaining varying amounts of allantoin. Theobject of this was to discover whether the allantoinwas destructive to the small and simple forms ofanimal and vegetable life which are found in the

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30 AN ANCIENT REMEDY AND ITS MODERN UTILITIES CLINICAL OBSERVATIONS 31

plankton. Owing to the active way in which theymove about, the most easily observed creatureswere the copepoda, but there were many otherforms which could easily be watched with thenaked eye. An excess of allantoin was placed in aquantity of sea-water and thoroughly shaken up,so as to make as saturated a solution as possible,and of this quantities were added to newly drawnsea-water in proportions varying from 1: 8, 1: 7,and so forth up to saturated strength, controls ofpure sea-water being employed in every series ofexperiments. The net result of a considerablenumber of observations was that the animalculreobserved lived for nearly as long a time (abouttwo days) in the saturated and other solutions asthey did in the controls, and from this it appearedthat allantoin was not appreciably inimical to theforms of life which were experimented upon.

On my return to Liverpool Dr. Alfred Adams,working in the Biochemical Laboratories of theUniversity, made some experiments with variousculture media, containing O· 2 per cent. of allantoin,and on November 1, 1911, he reported that theBacillus coli, Staphylococci, Streptococci andTubercle Bacilli were not retarded in their growthand multiplication by it.

Allantoin, then, is not an antiseptic in the usualacceptation of the term, and its action in thisrespect must depend upon some influence broughtto bear upon the cells, whereby _their resistance,stability and immunity are established and theirproliferation promoted.

It has been explained that sundry independentworkers had reported their experiences, and beforegoing further one or two of these may be mentioned.

In February, 1912, Dr. Mackenzie Forbes ofMontreal was supplied with allantoin wherewith

to treat a case of senile gangrene in the heel of anaged colleague who had been glycosuric for someyears and had sclerosed vessels. He had been inbed for five weeks suffering much pain and theslough had not separated. The necrosed area wasdescribed as being over an inch in diameter andfrom half to three-quarters of an inch deep, thismeasurement being due to infiltration of the sur­rounding tissues. The necrosis extended down tothe os calcis; it was not thought, however, thatthe periosteum had been denuded. The allantoinwas at once applied on its arrival in 0·5 per cent.solution, and immediately promoted cleaning up,separation of the slough and much relief from pain.The report stated that there was a continuousimprovement after the new dressing was employed,and the cavity ultimately closed with a stellatescar.

The late Dr. Arthur Wallace (Surgeon to theLiverpool Women's Hospital), reported the closureof an intractable biliary fistula following operationfor gall-stones. Ten days after the first dressingwith allantoin solution, applied by means of a gauzewick, bile ceased to escape and the sinus steadilyhealed. He reported another case of local necrosisfollowing a pressure sore and others in which drainagetube tracks had been slow in healing which weregreatly benefited by treatment on similar lines.

An ophthalmic surgeon employed allantoin dres­sings for a patient having a very extensive and deepburn of the eyeball ap.d lids, due to molten copper,and expressed himself astonished at the result.He wrote: "The disappearance of the chemosis,the finn healing of the deeper layers and theformation of new tissue have been most markedand have even astonished the nurses who knownothing about the stuff."·

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32 AN ANCIENT REMEDY AND ITS MODERN UTILITIES CLINICAL OBSERVATIONS 33

There were many other writers on the subjectbut it would only labour the point to refer to theircomments and expressions concerning the effectsproduced in the way of cell-proliferation.

Just a few words may be permitted concerningthe use of allantoin in internal ulcerative conditionswhere no ocular demonstrations of the healingprocesses have been possible. Comfrey was muchused bv medical men in the seventeenth andeightee{;th centuries for those" Bursten Within," i.e.in cases of hoomatemesis and hoomoptysis. Theyhad much faith in it. Was this justified 1 No doubtmuch would depend on the natures of the diseasesconcerned. Some would probably be ulcers in thestomach and duodenum, others were possiblymalignant growths. In chest cases they evidentlytreated phthisical hoomorrhages with it.

In the course of the past twenty years there havebeen many opportunities for testing the situation,and one can only infer that whereas there are casesof internal ulcerative conditions in which improve­ment has been noted, there have been a good manyin which the results were doubtful. One can onlyspeak with any degree of certainty when diagnosishas been clear and where beneficial results have notfollowed other forms of medicinal treatment. Onesuch experience occurred in the case of an elderlyman who after suffering pain after food, vomitingof blood, meloona, and other clinical evidences ofulceration which were unrelieved by medicinaltreatment, finally submitted to operation. Henearly died on the table after the stomach, having avery evident ulcer in it, had been exposed. Theoperation had to be abandoned and so far as localconditions were concerned he remained in statu quoante. He was then treated with allantoin dissolvedin a Comfrey infusion and a purely milk diet was

prescribed, with the result that he was free fromsigns and symptoms in a month and is still aliveat 90 odd years of age.

There have been good results and uncertain onesin cases of gastric and duodenal ulcers, but mygeneral impression is that allantoin and Comfreyare useful adjuncts to general dietetic treatment.

The following extreme case suggests that allantoinmay find useful application in gastric and otherinternal ulcerations :-

On February 17, 1911, a woman, aged 47, wasadmitted into my ward in an extremely debilitated.condition in consequence of a severe attack ofhoomatemesis. For many weeks previously shehad suffered from pain after food, and had vomited.persistently for a fortnight prior to her admission.Even water caused pain and was immediatelyrejected. There had been meloona for some timeprior to the attack of hoomatemesis for which shewas immediately admitted. For twelve monthsshe had been conscious of pain on pressure over theabdomen, and had noticed a lump in the epigastriumand extending into the right hypochondrium. Thiswoman was so feeble that the ward sister said thatshe thought it was a pity that a patient so ill andadvanced in disease should be sent into the hospital.I felt disposed to agree with this opinion, becauseon examining her abdomen I found a tumour justunderneath the ribs on the right side. It wasrounded, irregular, and intensely painful, and myfeeling at the time was that she had a carcinomainvolving the stomach, and this opinion was streng­thened by the fact that she had an undoubtedcarcinoma of the breast. When the irritability ofthe stomach subsided she was given the mucilaginousinfusion of Comfrey root reinforced with some ofthe saturated solution of allantoin. In addition

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34 AN ANCIENT REMEDY AND ITS MODERN UTILITIES

to the improvement which took place in her stomachsymptoms, in the course of a month the abdominaltu~our disappeared, an area remaining, however,which was extremely painful on pressure; but intime this also disappeared, and what I had takento be a malignant growth had vanished.

I have treated other cases of gastric and duodenalulcers in the same way, and have reason to believethat it is a helpful measure for them.

RELATION OF ALLANTOIN AS ACELL-PROLIFERANT IN CASES OF

MALIGNANCY

HAVING demonstrated that allantoin is asubstance capable of being utilized both byvegetable and animal cells in connection

with their proliferative processes, the next point todetermine was whether it produced any influenceupon malignant cell-growth. A good many caseshave been recorded where cancerous, or sarcomatousgrowths are reputed to have been benefited bytreatment with Comfrey. They are mentionedamong the "vertues" in some of the old Herbals.We have a modern example in the case referred toby Professor William Thompson (p. 1), and therehave been others which led to our trying the effectof Comfrey and allantoin when applied locally incases of advanced and ulcerating cancerous growths.Except in the case of rodent ulcer referred to onp. 11, no definite signs of improvement were noted.·Whether consequent mitotic changes took placewas not determined, and so far as at present observedit can only be stated that Comfrey and allantoin donot appear to have any capacity for producing asomatic cell from a malignant one, or a carcinomatousor sarcomatous cell from a somatic one, and noreasonable explanation can be afforded for theoccasional cures which have followed their employ­ment.

From its influences on normal cells it can onlybe inferred that since allantoin leads to their pro­liferation it may possibly have something to dowith the activities of nucleic acid. If this is the

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36 AN ANCIENT REMEDY AND ITS MODERN UTILITIES

case a study of the structure and building-up ofnucleic acid may in the future prove to be of someimportance. It was at one time believed that itconsisted of four metaphosphoric acid residues,each linked to a pentose molecule (the sugar ribose)and to one molecule resPeCtively of the purine basesadenine and guanine, and one each of the pyrimidinederivatives thymine and cytosine. It is to the twopurine bases that allantoin may be indirectly related,since they both yield uric acid in the course of theirchemical metabolism, whilst uric acid when suitablyoxidized yields allantoin. Nucleic acid and sodiumnucleate have for some time been known to increasethe count of white blood-corpuscles in cases ofpneumonia, and it has been supposed that theindirect relationship of allantoin to nucleic acidmay to some extent be responsible for this. Dr.Titherley informs me that it is now generally believedthat the phosphoric acid residue in nucleic acid isthat of common ortho-phosphoric acid and thatLevene now considers that the four nucleotides(phosphoric - pentose sugar-purine - pyrimidine)are linked through the pentose groupings thus:-

/Pentose sugar-adeninePhosphoric acid residue,

Pentose sugar-thyminePhosphoric acid residue/

'Pentose sugar-guaninePhosphoric acid residue/

.......Pentose sugar---eytosinePhosphoric acid residue/

This is contrary to Kossel's formulation of thephosphoric acid residues as being linked togetherthemselves, also each being independently linkedto the pentose sugar. Another authority (W. Jones)does not link the phosphoric acid residues either in

ALLANTOIN AS CELL-PROLIFERANT IN MALIGNANCY 37

the manner of Kossel or of Levene but links thepentose sugar residues together (not through phos­phoric acid) and each independently to a phosphoricacid residue, leaving each phosphoric acid residueto contain two hydroxyl groups. Levene's formula­tion gives one hydroxyl group in three of the residuesand two in the fourth.

It seems reasonable to suppose that cellularstability may depend upon the efficient building-up ofnucleic acid, and as some of the experiments onplants have suggested, this probably results from ametabolic process in the cells. On this accountthere would appear to be little use in giving orapplying nucleic acid (01' nucleo-protein) when it isdesired to build up that protein in the cells. Itsooms likely that they cannot make use of the fullyformed material but require to assimilate theconstituents required for cellular growth, structureand stability. On this account experiments mightbe directed towards the discovery of the effectsupon cell growth of the various constituents ofnucleic acid.

As previously stated, the connection betweennucleic acid and allantoin is a very indirect one,and there is no real evidence that the latter buildsup the adenine and guanine components of nucleicacid. At present this is in the realms of hypothesis.

The only substances which have been experimentedwith up to the present have been Meta- and Ortho­phosphoric acids which in dilute solutions (! to I percent.) have certainly been found useful in thetreatment of old sinuses and abscess cavities whichwere showing little signs of closing. The resultsof washing them out with these solutions haveproved very satisfactory.

Finally, a survey of the results of using decoctionsof the Symphytum officinale and solutions of allantoin

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38 .AN ANCIENT REMEDY AND ITS MODERN UTILITIES

in cases of alleged malignancy brings out the sugges­tive observation that nearly every case in whichbenefit seemed to ensue was treated either with thedecoctions alone or sometimes with the addition ofsmall amounts of allantoin. In Professor Thompson'scase the patient inferred that the growth was dis­persed by the local application of Comfrey poUltices(p. 2). The case of rodent ulcer which improvedso greatly (p. 11) was treated in the first place withComfrey mucilage and afterwards with allantoinextracted from the rhizome. The woman sufferingfrom an apparently malignant growth involvingthe stomach (p. 33) cleared up under the adminis­tration of a mucilaginous decoction of the rhizomereinforced with the synthetic allantoin.

These and other cases, not recorded in the text,lead to conjecture as to the possibility that theoptically active d-allantoin (p. 57) in the Comfrey andother vegetable and animal structures may havebiological influences on cells different from, or acces­sory to, those produced by the synthetic (raceInic)product which, however, undoubtedly acts as acell-proliferant and promotes healing as heretoforedescribed. By analogy it may be- surmised thatnatural products are lmperior to their syntheticisomers in their biochemical activities. Take forexample the case of glucose uf which the opticallyactive d-form is an essential element in metabolism,whereas the synthetic l-glucose is not valuable asa foodstuff. The difference between the naturald-glucose and its image-isomer l-glucose is of thesame type as that between the d- and £-allantoins(i.e. in optical activity and asymmetric arrangementof atollls). In all chemical properties they are (inboth cases) identical, yet biochemically the twoforms of glucose are completely different and itseems possible that some difference in biochemical

ALLANTOIN AS CELL-PROLIFERANT IN MALIGNANCY 39

activi~y may also exist in the case of the allantoins.~ractlCal ~xperience tells us that synthetic allantoinIS an actIve agent, but the question arises as towhether the natural form found in the allantoisin milk, a~d in variou~ vegetable structures may notpossess virtues supel'lor to those of its syntheticIsomer.~or all we. k~ow allantoin may have some physio­

lo~pcal aSSOCIatIOn with other elements found in theammal or plant such as endocrines or vitamin Bw~c~ may i~fluence its therapeutic properties. On~stri~ng pomt comlected with its action is therel.atlvely small ~mount required in solution to setgomga local he~li~g p:ocess, e.g. by application to anulc~r, or.a multIplicatIOn of leucocytes ,in the bloodwhich ":Ill be referred to presently, in this respectresembling a hormone.

This ends the p~mary investigation concerningthe Symphytum offic~nale and its contained allantoinmuch of which was published in the British MedicalJou1-nal (January 6 and September 21, 1912).

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FURTHER OBSERVATIONSCONCERNING ALLANTOIN, 1914-1935

IN connection with the local application ofallantoin to septic and sloughing sudacesattention has been directed to the " cleaning­

up" process which takes place as a preliminary to,or concomitantly with, the ingrowth of epithelialcells from the margins of ulcers and from the isletsof epithelium on the surfaces of burns. This wasoriginally ascribed only to an increase in the vitalityor resistance in the cells themselves, but the pointarose as to whether this might not be brought about,in part at any rate, by some change in the cellularenvironment. That the cleaning-up did not resultfrom a chemical antiseptic action was indicated by

. the absence of such properties in the allantoin itself,and by the circumstance that many of the ulcershad failed to clean up or heal when treated byvarious antiseptics before the solution of allantoinha,d been applied. The question thus arose as towhether this lessening or inhibition of sepsis resultedfrom a promotion of phagocytosis.

Some light was thrown on this by Drs. AlbertBerthelot and D. M. Bertrand in a research carriedout in the Pasteur Institute, the results of whichwere published in August, 1912.1 This researchwas promoted by their notice of my publication in theBritish Medical Journal, January 6, 1912. It hadoccurred to them that allantoin might act by stimula­tion of phagocytosis, and they studied its actionby experiment on guinea-pigs.

1 Comptes Rendus Hebdomadaires des Seances de la Societe deBiologie, lxxiii, 2nd Aug., 1912, p. 263.

OBSERVA.TIONS CONOERNING .A.LLA.NTOIN, 1914-35 41

Three cubic centimetres of a saturated solution ofallantoin were injected into the peritoneal cavityof a guinea-pi. Eighteen hours afterwards theydetected the presence of a light peritoneal exudatecontaining polynuclear cells. In order to obtain amore abundant leucocytosis 10 cgm. of finely pul­verized allantoin were suspended in 5 C.c. of water,which after sterilization was injected into theperitoneal cavities of two animals, and twentyhours later a discharge of purulent liquid, composedentirely of absolutely aseptic polynuclear cells, waswithdrawn by means of a fine pipette. They theninjected similar allantoin suspensions into severalother guinea-pigs, varying in weight from 350 to400 grm., and twenty-four hours afterwards, havingdetennined the presence of a very abundant peri­toneal exudate, they injected into one of them afatal dose of a young culture of cholera vibrio, andinto the other a similar fatal dose of Eberth'sbacillus. Control animals were injected at thesame time with similar fatal doses.

All the control animals died in from twelve tonineteen hours, whereas the animals which hadreceived the allantoin were unaffected' and survived.The peritoneal exudate taken from these latteranimals, twenty hours after the injection of themicrobes, was sterile, and was composed of leuco­cytes, some few of which contained granules whichmight have been the debris of dead bacteria. Fromthese experiments the authors concluded thatallantoin was capable of strengthening the localresistance of the peritoneum against infection andof causing a considerable leucocytosis; and theysuggested that the favourable action of allantoin wasprobably attributable, in part at all events, to this.

These experiments, and the observations made byclinicians concerning the cleaning-up of septic

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42 AN ANCIENT REMEDY AND ITS MODERN UTILITIES

surfaces, opened up a new field of inquiry, for itseemed possible that if the local application ofallantoin promoted a multiplication of phagocytes,it might also, if introduced into the blood, set up ageneral leucocytosis, and that if this proved to be thecase a controlling influence might be exerted oninfective diseases, and especially perhaps in thosetypes of cases where there is a controlled immunity.It is well known for instance that immuirity frompneumonia is diminished when other diseases suchas influenza ~in which, by the way, there is a leuco­pamia1 lower the vital resistance. This reSistance,strange to say, is diminished in some conditionswhich improve the general health. We seldom comeacross pneumonia among sailors or passengers whenthey are at sea. It is on arriving at the ports whentheir leucocytes are off guard that they are liable tobecome victims. Everybody recogniies how pronewe are to get catarrhal colds after arrival in theto",-ns from a sea voyage or from a holiday in arelatively germ-free atmosphere. This tendencyto infection was recognized by the physicians of apast generation. I recollect the late Dr. WilliamCarter about forty years ago warning me, on mysuggestion of Spitzbergen for a holiday, that therewas a risk of becoming infected with pneumonia onreturning to my hospital work. At that time,however, I do not thin~ that the function of theleucocytes as infection-preventers was much under­stood.

Pneumonia is to some extent an unsatisfactorydisease on which to make unambiguous observationsbecause severe cases often recover, whatever treat­ment may be adopted, and there is also the fact thatthe strain of pneumonia organism prevalent atone period may differ in virulence from that ofanother.

OBSERVATIONS CONCERNING ALLANTOIN, 1914-35 43

It so happened that the first suitable cases whichcame before me for observation were severe lobarpneumonias, and it will be best to record the historyof this clinical investigation which was commencedin 1914, in order of sequence. One of the earliestcases treated made a somewhat unexpected recovery.The patient, a quartermaster on one of the liners,was desperately ill and his blood had a very lowleucocyte count, only about 6,000 per c.mm., apoint which always makes for a bad prognosis inthe later stages of pneumonia. There was a possi­bility of there being a small amount of fluid in hischest, and thinking that its removal might helpmatters I needled the chest but got nothing butblood from the solidified lung. Without removingthe needle I then slowly injected 2 c.c. of an 0'5 percent. sterile solution of allantoin into the solidlung. Within two hours the leucocyte count hadgone up to 15,000; later it was 20,000 and with thisincrement there was distinct improvement and aspeedy crisis. A possible explanation, however, ina case of this kind is the fact that simple punctureof the lung will sometimes precipitate a crisis 'andin some chronic types will similarly promote resolu­tion. I pointed this out long ago in a paper entitled"Puncture of the Lung in Chronic PneumonicConditions." 1

In order to eliminate the possible influences oflung puncture, I proceeded to give my patientsallantoin by hypodermic injection, and was encour­aged to a certain extent by what appeared to beresultant benefits. For instance, in the case of aman, aged 23, whose leucocyte count in the laterstage of the disease was 9,000 per c.mm., 2 c.c. ofthe O· 5 per cent. solution of allantoin was givenhypodermically. In two hours the count had1 Published in the Livel'pool Me4. ChiI'. Jour». of March, 1901.

4

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44 AN ANCIENT REMEDY AND ITS MODERN UTILITIES

risen to 12,000 and after another injection it wentup to about 20,000 and remained high until thecrisis occurred. Such cases were encouraging butthere were admittedly a considerable number offailures and one could by no means speak withcertainty as to what might accrue from this methodof treatment.

The point was that at that period I was onlyusing allantoin as a kind of dernier re880rt in thelater stages of grave or apparently hopeless casespresenting indications of serious toxremia. Manyof these cases already exhibited a considerableleucocytosis which was not materially influencedby allantoin, and the unsatisfactory results weredue to cardiac failure brought about by the toxremia.In consequence of this the use of allantoin wasabandoned in these grave cases; the fact remained,however, that it had conferred benefit in some casespresenting a low count, and this led to an entirechange of procedure which resulted in a very differentcourse of events. The allantoin was now given inthe earliest instead of the later stages of the disease,and for the efficient clinical observations of thesecases I am greatly indebted to Dr. Edward BlairWilkinson, who was my Resident at the time, andto my student Mr. N. Green, who took a greatinterest in the subject and read his thesis for theCambridge degree on it.

ALLANTOIN AND LEUCOCYTOSIS.

The first experiments were carried out in normalhealthy individuals, to whom a grain of allantoinin solution was given by mouth at two-hourlyintervals on an empty stomach. The counts weregenerally taken two hours after each of three suc­cessive doses. The polynuclear cells were increased

OBSERVATIONS CONCERNING ALLANTOIN, 1914-35 45

by from 5 to 15 per cent., and it was noted bymaking subsequent counts that they had returnedto the normal in from sixteen to forty-eight hours.

Next came the administration of allantoin to casesof pneumonia commencing at the earliest possibleperiods after the onset of the disease, with theresult that a rapid increase in the number of leuco­cytes was generally observed. In many cases it wasnoted that the crisis was early, this being influencedby the shortness of the period, following the onsetof the disease prior to the administration of allantoin.For instance, in nine cases where the crisis tookplace on or before the seventh day the allantoinhad been given within the first seventy-twohours, whereas in six cases in which it had beencommenced after the first seventy-two hours thecrisis occurred on or after the eighth day.

A very striking instance of the benefit resultingfrom early administration was in a patient who hadbeen operated on for gall-stones. He had a suddenrise of temperature with rigor, pain at the base ofthe left chest, where there were undoubted signsof early pulmonary consolidation including impair­ment of the percussion note, bronchial breathingand some fine crepitant sounds. No blood-countwas taken but allantoin was given intensively, 2 gr.in solution at two-hourly intervals, and withinforty-eight hours the temperature was normal andthe condition practically cleared up. In anothercase which I saw at the Bourton-on-the-WaterhospitaP in 1933, where a pneumonia had commencedin a very stormy way, accompanied by pericarditis,a similar speedy resolution took place, but wasfollowed by an empyema. (Empyema has onseveral occasions followed in cases of pneumoniatreated with allantoin, and a conjecture has arisen

1 With Dr. Leslie King.

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46 AN ANCIENT REMEDY AND ITS MODERN UTILITIES

as to the possibility of it resulting from what may becalled a hyper-leucocytosis.)

With reference to the period of crisis Mr. Greenrecorded that out of 15 cases of frank lobar pneumoniatreated with allantoin during a period of twelvemonths, the crises occurred as follows:-

One case on the 4th dayOne case " " 5th dayFive cases" " 6th dayT"\\,o cases " " 7th dayThree cases " " 8th dayOne case " " 11th dayTwo cases " " 12th day

In nine of these cases the crisis occurred on or beforethe seventh da;r, and in six of them on or after theeighth day. In the former group the allantoin wasgiven, with two exceptions, well within the firstseventv-two hours from the onset. and in the lattergroup ~after the first seventy-two 'hours, with threeexceptions, one of which was a very severe case withinvolvement of almost the whole of both lungs.

A point to note in connection with the course ofpneumoniu,s treated with allantoin (also observedby Mr. Green) is the occurrence of a pseudo-crisisgenerally from twenty to thirty hours after thedrug was first given, the temperature dropping tonormal and remaining so for a few hours, but withoutmuch relief from symptoms. Occasionally one ortwo such falls in temperature preceded the truecrisis. Mr. Green suggested that the pseudo-crisismight be explained by an abnormally rapid increasein the leucocytes causing a temporary check to themultiplication of pneumococci and production oftheir toxins in the blood-stream, enabling thethennal centre to regain its balance for a while.The symptoms are not abated during the pseudo-

OBSERVATIONS CONCERNL.~GALLANTOIN, 1914-35 47

crisis because the lung condition remains unchanged,and the disordered circulation in the lung does notenable many of the newly formed leucocytes topenetrate and attack its contained pneumococci.

That allantoin renders a useful service in pneu­monia is indicated by the relatively low mortalityof patients treated with it as compared with thegeneral run of cases treated on the usual therapeuticprinciples. At the time when Mr. Green worked inthis investigation there were ample opportunitiesfor making comparative observations. Over aperiod of two years 47 cases of lobar pneumoniahad been treated in the hospital,and in that periodmost of the cases in my own wards had been givenallantoin, but very few of those in other wards.At any period in those two years the cases would beof somewhat similar strains, or at all events theywould be fairly evenly mixed. Twenty-five ofthe 47 cases were treated on the usual therapeuticlines, the remaining 22 cases were given allantoinby mouth, some of them with such additionalmedicines as might be required to meet symptoms.The mortality in theformer group was 20 per cent.,whereas in the latter it was under 5 per cent.. Making all allo~ances for conditions which mightmfluence prognosIs such,as questions of age, prece­dent or collateral infections, etc., it seems evidentthat there must have been some relationship betweenthe diminished mortality and the administrationof allantoin.

During the past eight years Dr. Robert Stewart and'other medical men practising in and around Bourton­on-the-Water have, without making any leucocytecounts, treated their pneumonias both in and out ofhospital on the principles above referred to and theirexperiences have been definitely satisfactory.l

1 vide Addendum page 52.

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48 AN ANCIENT REMEDY AND ITS MODERN UTILITIES

During the past three years (1932-35) a series ofclinical observations have been made with allantoinwith a view to confirming or otherwise the presump­tion that it produces a leucocytosis when adminis­tered by mouth. In 1932 I sent a quantity of thecrystals, which had been in my possession for a yearor more, to Dr. Norman Capon of Liverpool, andhis former Resident, Dr. O. Vaughan Jones, kindlycarried out a series of investigations, the generalresults of which were distinctlv confirmatorv. Theallantoin was given to 20 individuals whose le"ucocytecounts were within normal limits. To each of themhe gave 2 gr. of allantoin dissolved in one ounceof water at two-hourly intervals and, in order thatthe leucocytosis following the ingestion of foodshould be eliminated as far as possible, the blood­count in each case WD,S made from two and a half tothree hours after a meal. By way of control, blood­counts were made in five cases under the sameconditions, but without giving any allantoin. Ineveryone of the cases receiving allantoin a leuco­cytosis ensued ranging from 50 per cent. to 83 percent. increase in seven instances, and from 25 percent. to 47 per cent. in the remaining 13 cases. Noneof the controls showed appreciable changes. Theaverage increase was somewhat low compared withthe results in some of my own original observationsand those of the staff in the pathological laboratoryof the Royal Southern Hospital, from ten to fifteenyears ago, and one rather suspected that the crystalsof allantoin might have deteriorated. It so hap­pened that in 1934 I sent a supply of the same stockof crystals to Dr. M. Schwartzman who was interestedin the matter, and he reported that in a limitednumber of observations his results were not con­vincing. This led him to obtain some freshlyprepared allantoin which he administered, in accord-

OBSERVATIONS CONCERNING ALLANTOIN, 1914-35 49

ance with the recommended instructions, to 19 peoplewho were either in normal health or the subjectsof diseases presenting no blood changes, and incourse of conversation he informed me that in 17 ofthem positive results up to 65 per cent. increasein the number of leucocytes were obtained.

It seems just possible, therefore, that syntheticallantoin crystals, although supposed to be quitestable, may deteriorate with keeping, and if so itis advisable to use crystals which are not too oldkept absolutely dry in a well-stoppered bottle.It is at present uncertain how long they will keepin an unimpaired condition, but crystals freshlyprepared seven months ago, so kept, have certainlyproved perfectly active in a number of recentlyinvestigated bloods.

I have already explained that solutions shouldbe made with distilled water, and that heat short ofboiling should be employed in their preparation.It is advisable to powder the crystals finely firstin a perfectly clean mortar, and then use only hotdistilled water, stirring well to get the solid i~to

solution, of course using a chemically clean glasstest tube or beaker and glass rod.

In conclusion it may be said that although lobarpneumonia has been the disease mainly investigatedwith reference to the action of allantoin in pro­ducing phagocytosis, it may prove useful in otherinfective conditions which might be benefited by theproduction of a leucocytosis. It has been foundserviceable in some cases of bronchopneumonia,and in some septic infections, and even the commoncold seems sometimes to have been averted whenthe drug has been given at the commencement.Its employment in the early stages of influenzaand in other diseases associated with leucopreniamight be usefully investigated.

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50 AN ANCIENT REMEDY AND ITS MODERN UTILITIES

Its utility as a promoter of healing in wounds,ulcers, and sinuses has already been appreciated inthis and other countries, and it is generally recog­nized that the best way of applying it is on sterilizedlint or gauze without waterproof coverings. Oint­ments having lanoline bases which are capable ofholding solutions of allantoin have proved useful.

A curious suggestion has recently come fromAmerica, l following the discovery made by entomo­logists of the U.S. Department of Agriculture, thatmaggots of certain flies when placed on woundspromote their healing. In this connection Dr.William Robinson, of the Bureau of Entomology andPlant Quarantine, found that allantoin given offby the maggots is responsible for at least a partof the healing power they possess, and the articlegoes on to state that surgeons who have found itdifficult in the past to obtain sterile maggots laudthe discovery that allantoin, which is spoken of as anew treatment, can be made to control healing.

The impression gained as to the cell-proliferatingproperty of allantoin is that it acts like a hormone,in the sense that such small quantities of it setgoing proliferations of considerable magnitude.

1 Drug Tl'ade News, April 29, 1935.

PREPARATION AND ADMINISTRATIONOF ALLANTOIN SOLUTION

FOR internal administration or local applicationof allantoin it is essential to use freshlyprepared solutions of which the most con­

venient strength is 0'4 per cent. This is approxi­mately 2 grains to the ounce. Allantoin is verysensitive to the action of alkalis, and on thisaccount distilled water should be used for making thesolutions.

Although prolonged heating decomposes allantoin,it has been found that water just below theboiling point may be used for dissolving it withoutappreciable decomposition, provided the solutionis quickly cooled.

Another point to remember is that though it isgenerally supposed that the crystals are quite stableand may be kept for any length of time, clinicalexperience has indicated that they are apt to losetheir efficiency if kept too long. Care should there­fore be taken to use crystals which are not too oldand which have been safeguarded against damp bykeeping them in well-stoppered bottles. Theyappear to remain stable for at least foUl' months,and probably considerably longer if kept perfectlydry.

Solutions of allantoin should be freshly preparedin sufficient quantity for nsc during a period notexceeding twenty-four hours.

Experiments on plants in which older solutionshave been used have shown that thev are less activethan freshly prepared ones. .

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52 AN ANCIENT REMEDY AND ITS MODERN UTILITIES

ADDENDUM.

Dr. Robert Stewart has treated many cases, bothof lobar pneumonia and bronchopneumonia withallantoin, and has no doubt that it does goodprovided it is given early enough. He regards it asa defensive measure, preventive as well as curative,in that it appears to lessen the extension of thedisease. His contention is that the important pointis to promote an early leucocytosis, before thedisease becomes systemic, and that by so doing therecomes a possibility of limiting the pulmonary involve­ment. He has recorded notes of two cases treatedin the Moore Cottage Hospital, Bourton-on-the­Water in January and February, 1936. The firstwas a man aged 47 suffering from a classic pneumoniafor which the treatment was commenced withintwenty-four hours of its onset. There was a massiveinvolvement of his right lung. Two grains of finelypulverized allantoin crystals were given every hourfor twelve doses. This was followed by a character­istic series of pseudo-crises and a final crisis on thesixth day. The second case illustrates a resultfollowing immediate treatment in a woman whosepneumonia developed while she was in hospital.She was admitted for a pleurisy of two days' dura­tion. On the evening of her admission her tem­perature shot up to 103·5° and she developed signsat the right base. Two grains of pulverized allantoinwere immediately given at hourly intervals andwithin thirty-six hours she had a typical crisis.

Dr. Stewart has found that in a country practice,where many of the patients live in distant places,time was wasted by the preparation of solutionsof allantoin for administration. This led to hisadopting the plan of having it dispensed in the formof powders. The insolubility of the crystals hadhitherto rendered this means of administration

PREPARATION AND ADlIlINISTRATION OF ALLANTOIN 53

unlikely to be so serviceable as when they were pre­dissolved but, judging by results, it is evidentlyeffective.

Following this record of experiences I experi­m~nted on some bulbous plants by injecting themWIth finely pulverized allantoin suspended in dis­tilled water in quantities considerably above satura­tion point. For instance, twenty-four hyacinthshaving shoots about 1 inch high were planted in abox. Twelve of them were injected with 10 minimsof the suspension, the remainder being controls.The idea was to introduce a store into the bulb,which would be gradually drawn upon, thus avoidinO'repeated injections. In four weeks the injectedbulbs were in bloom, whereas the controls had onl.­reached the stage when the enlarging flower-bud.,>had become visible, thus being far behind theirtreated neighbours. This experiment was repeatedwith a series of tulips and daffodils with similarresults.

Having exhaustively told the storv of the researc!iwhich led to the discovery of ';llantoin in theSymphytum officinale, and of the evidences of itsutility, it remains for others to derive conclusionsfrom their own clinical experiences ,vith it.

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......NH.CO NHz......co' I co

......NH.CH-NH .......

II.

THE CHEMICAL CONSTITUTIONOF ALLANTOIN

A. W. TITHERLEY, D.Sc., PH.D., F.I.C.,FO'rmerly Lecturer on Organic Ohemistry, University

of Liverpool.

IN a communication to the Chemical Society in1913,1 I showed that the accepted formulafor allantoin originally devised by Grimaux :­

.......NH.COco I

......NH.CH-NH.CO.NHz

will not explain all its properties, and especially itsoptical inactivity. Its molecule on Grimaux' for­mula contains an asymmetric carbon atom, namelythat contained in the CH grouping, and like othercompounds containing an asymmetric carbon atom,allantoin should be optically active. By this it ismeant that when a ray of polarized light is passedthrough its solutions the plane of polarization shouldnot be undefiected as it would be with water,alcohol, etc., whose molecules are symmetrical,but rotated either to the right or left, as it is forexample with the unsymmetrical molecule lacticacid, CHao CH. (OH) COOH.

An inspection of the latter formula showsthat the central carbon atom is asymmetric, i.e.linked to four different groups, just as is the above­mentioned carbon atom in the Grimaux formula.Lactic acid appears in two forms, both opticallyactive, in opposite senses, one, d-lactic acid, rotating

1 Journal of the Chemical SOGiety Trans., cill, 1336.

THE CHEMICAL CONSTITUTION OF ALLANTOIN 55

the plane of polarized light to the right, and theother, l-lactic acid, rotating it to the left to anexactly equal degree.

In 1913, in order to explain what appeared to bethe optical abnormality of allantoin, I supposedit to be a tautomeric substance in which a double­ring formula (I) alternated reversibly with that ofGrimaux (II), thus :-

OHI

......NH-C-NH...... +-co I co

"NH CH-NH....... ~

1.

This alternation between I and II is promotedby the shift in position of one of the hydrogenatoms, believed to be mobile, a shift which byanalogy with certain other types of molecule shouldbe an easy one. Granting such a shift, involvinga tautomeric change between two distinct formulre,the optical inactivity was easily explained sinceFormula I is strictly symmetrical, and whenit changesback to Formula II, containing an asymmetriccarbon atom, it must yield an equal number ofmolecules which are dextro-rotatory (d-) to thosewhich are lrevo-rotatory (l-), since there is nothingto determine a preponderance of one form; and thed-l- mixture must be optically inactive by compen­sation, as each form must be equal and opposite inthe degree of optical rotation.

Apart from the above, there were other (chemical)reasons in favour of Formula I, being at least oneof the possible tautomeric forms of allantoin, thoughthese reasons need not be considered here.

This theory of tautomerism has quite recently(1934) received indirect confirmation by the re­searches in France of Fosse, Thomas and Graeve

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56 AN ANCIENT REMEDY AND ITS MODERN UTILITIES

(Comptes rendus, 198, 685, 1373, 1953). Theyhave shown that it is actually possible to prepareoptically active forms of allantoin if great care isexercised to prevent what is called racemization,Racemization is a well-known phenomenon inorganic chemistry, viz. one by which an opticallyactive compound loses its activity by conversioninto an optically inactive mixture (equi-molecularof d- and l- forms). Thus, suppose a given compoundis wholly the d-form: on certain chemical treatment,more or less drastic, this d-form may change intothe l-form, and as more and more molecules of thed-form go over the rate slows down because thereverse thing is happening (under the given treat­ment) with the l-molecules, and finally a state ofequilibrium is attained when as many d-moleculesare being regenerated from the l-molecules as arebeing transposed into l-molecules. So if the processis followed by the proper optical instrument it isfound that the initial dextro-rotatory compoundsteadily loses its activity and ends by being com­pletely inactive, like water. It is now said to bea racemic mixture of d- and l- forms (in exactlyequal amount) and the process is, as above stated,called racemization. And so it turns out thatallantoin as ordinarily obtained is such a racemicmixture (or racemic compound) of the two forms,and if one of the two forms is isolated it passes withextreme ease into the racemic form, as it wouldbe expected to do if there is an alternation betweenthe two molecular formulre I and II.

Now it is a commonplace of Organic Chemistrythat asymmetric substances found in Nature arealmost invariably optically active, while the samesubstances produced synthetically are inactivebecause racemic (there being nothing to determinea preponderance of one of the forms by synthesis).

THE CHEMICAL CONSTITUTION OF ALLANTOIN 57

It is also a well-known phenomenon that when aracemic mixture is fermented by any means (say byenzymes), one of the two forms is more susceptibleto decomposition than the other, which sometimesis quite unaffected. To this rule allantoin is noexception. Natural allantoin when isolated fromnatural sources, by carefully controlled methodsto prevent racemization, is optically active asdemonstrated by the above authors. It is d-allantoinand has a specific rotation for polarized lightraJ": + 93° in water, and this hitherto unknownform of allantoin has been obtained from calves'urine and from certain plants, by extraction methodsavoiding all rise of temperature. In all ordinarychemical properties it is identical with commonallantoin, which is now recognized to be a racemiccompound of d- and l- allantoin, but it might besupposed, by analogy with other optically activecompounds, that there should be a biological dif­ference between d- and l- allantoin on the one hand,as well as between them and common (racemic)allantoin on the other. l-Allantoin has beenobtained by the above authors from the latter byby taking advantage of selective differences in therate of destruction at 40° C. of the two forms, by anenzyme, from soya bean, called allantoinase, thel-form preferentially surviving, as the d-allantoinferments more rapidly.

Both d- and l- allantoin are exactly alike, exceptin respect of what might be termed asymmetricproperties such as optical activity, where they areopposite and equal. Each on warming in solutionpasses over into the racemic form, common allantoin.

It is well known that many of the bio-chemicalmanifestations of living matter are concerned withthe transformation (such as oxidation, reduction,hydrolysis, etc.) of complex asymmetric compounds,

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58 AN ANCIENT REMEDY AND ITS MODERN UTILITIES

proteins, carbohydrates, phosphatides and so on,most of which display optical activity and are there­fore not racemic forms. Indeed chemical asymmetryplays a fundamental role in life, as is well knownfrom numerous cases which have been established,and probably allantoin is no exception to this.It is apparently the unstable d-form which, so faras is known, normally functions in the .living plantand animal. When therefore ordinary racemic(d-l) allantoin is applied therapeutically it may bepresumed provisionally that only one half of it (d-)is active and the other half (l-) is inert, but as yetnothing definite is known about this. In any casewhen ordinary allantoin is brought into solution byheating with water it no doubt passes partly intothe symmetrical double-ring form I (p. 55) and evenwith cold water it is probable that a small quantityof I co-exists in solution with the asymmetric form II,and the equilibrium between these two forms, I andII, will be disturbed by numerous chemical agencies.For instance, the influence of acids and alkalis wuuldbe expected to be profound and thus the pH valueof the solution, as representing the concentration ofhydrogen (oxonium) ions will be a determining factorin this equilibrium. As is well known with pH 7,as it is in the purest distilled water, we have absoluteneutrality, meaning a very small but definite valuefor hydrogen-ion concentration. With small quan­tities of alkali present (even as dissolved out of glasswhen boiled with water) the pH rises, and when at avalue of say 8 or 9 there is a marked alkalinity.On a priori grounds this should favour a morerapid establishment of equilibrium 1:>etween formsI and II and also a preponderance of the asymmetricalform II, because this is the more acidic of the twoforms. Allantoin belongs to a group of chemicalsubstances known as amphoteric, because they

THE CHEMICAL CONSTITUTION OF ALLANTOIN 59

function as weak acids in their behaviour towardalkalis, forming alkali salts, and as weak basestowards acids, forming salts with such acids. Allan­toin, for example, yields a well-defined crystallinenitrate with nitric acid and it dissolves in causticsoda much more readily than it does in water becauseit forms a sodium salt (very unstable). It is alsoimportant to observe that allantoin as an acid isconsiderably stronger in hot aqueous solutionsthan it is in cold. When its aqueous solution isacid for any reason (say on heating or when acidis definitely added) the hydrogen-ion concentrationincreases. This, as in the case of alkali-effect, willpromote a more rapid attainment of equilibriumbetween forms I and II, but for certain chemicalreasons it is likely that it favours the predominanceof the symmetrical form 1.

We may sum up, then, by saying that allantoinwill be very sensitive to acidity and alkalinity, aswell as to high temperature, but that there is reasonnow (after the work of Fosse, Thomas, and Graeve)to believe that the predominating form in neutralsolution (pH = 7) in the cold is the asymmetricalform II.

Apart from these considerations,. affecting onlythe reversible equilibrium between form I and thetwo optically active forms (d- and l-) of II and readilyaccounting for the easy racemization of the latter,it must be noted that allantoin is a chemicallyunstable substance, readily converted by variouschemical agencies into the other chemical compoundsrelated to it, but in no way identical with it. Themost striking of these changes is that observed withstrong alkaline solutions. Here the first stage is itsconversion into the salt already referred to, but onstanding in the cold this salt decomposes by ruptureof the ling in Formula II yielding the salt of a definite

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60 AN ANCIENT REMEDY AND ITS MODERN UTILITIES

acid, called allantoic acid, which is itaell very unstableand may be converted into a number of derivatives,these being as yet but imperfectly understood. Itis quite possible that some of these derivativesappear in animal and vegetable life but have notbeen identified owing to their very soluble, sYrUpyand non-erystallizable nature.

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