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LOCAL EFFECTS OF SULPHONAMIDES ON THE RABBIT'S BRAIN
100
general condition of the patient ; the deflation of the blown-up abdomen is of secondary interest. REFERENCES
LOCAL EFFECTS OF SULPHONAMIDES ON THE RABBIT’S BRAIN
Tyrrell-Gray, H. (1936-37) Post-graduate Surgery, London, vol. i, pp. 1195, 1201. Robb, J. J. (1932), Brit. J. Surg. 19, 636. Cokkinis, A. J. (1936-37) Post-graduate Surgery, London, vol. i,
BY DOROTHY S.
AND
p. 1090. Dodd, H. (1938) Brit. med. J. 2, 624.
Flint, E.
R.
(1939) Post-grad.
RUSSELL, M.D. Lond.
WORKING FOR THE MEDICAL RESEARCH COUNCIL
MURRAY A. FALCONER, F.R.C.S.
med. J. 15, 234, 270.
(From
the
Nuffield Department of Surgery, Oxford University)
PFEIFFER’S-BACILLUS MENINGITIS TWO UNUSUAL
CASES
BY J. H. DOWDS, M.B., M.SC.
(From the Roan Antelope Hospital, Luanshya, Northern
Rhodesia) Ix the two following cases of Ffeiffer’s-bacillus meningitis the meningeal manifestations were apparently preceded by, and probably secondary to, subcutaneous abscesses containing Pfeiffer’s bacillus (Haemophillls tM.j!
other. CASE I.-A native boy, aged three or four months, was to hospital with a subcutaneous abscess of a few days’ duration over the right elbow. He was emaciated, his temperature was 100° F., and pulse-rate 120, regular, and of moderate volume. His chest and throat were clear, and there was no evidence of nervous trouble. The abscess was aspirated, less than 1 oz. of fluid brownish pus being drawn off ; this contained gram-negative bacilli having the cultural characteristics of Pfeiffer’s bacillus. Some bacilli showed
brought
bipolar staining. M. & B. 693, 0-16 g. followed by 0-08 g., was given thrice for five days, by which time the abscess had cleared up. The temperature remained at about 100° F. with occasional remissions for ten days, after which meningeal manifestations - heat retraction, transient deviation of the eyes to the left, and drawing up of the legs-were observed for the first time, though the nervous system had been examined daily. The fontanelle was not tense, and lumbar puncture yielded only a couple of drops of thick turbid fluid containing bacilli resembling those obtained from the abscess and culturally Pfeiffer’s bacillus. Treatment with M. & B. 693 was started again, 0-25 g. being given, followed by 0-12 g. thrice daily. A white-cell count done at this time showed 3900 leucocytes, of which 33 per cent. were lymphocytes, 15 per cent. monocytes, and the remaining 52 per cent. polymorphs (juvenile forms 28 per cent., stab forms 6 per cent., and segmented forms 18 per cent.). No myelocytes and no eosinophils were seen. The pulse became rapid, and the temperature dropped below normal, where it remained till the child died. At necropsy thick yellow pus was found over the vertex of the cerebrum, its base, and the brain stem. There was slight congestion at the bases of the lungs, and the kidneys were pale and fatty. CASE 2.-A native child, aged three and a half months, was admitted to hospital in a fairly healthy condition apart from swellings on the left arm and buttock. The swelling on the buttock was incised and pus evacuated containing gramnegative bacilli culturally identical with Pfeiffer’s bacillus. No signs or symptoms suggesting involvement of the central nervous system were noted. Treatment with M. & B. 693 was carried out as in case 1. The temperature, which was 100° F. on admission, settled in three days under treatment, the swelling on the arm cleared up spontaneously, and the buttock ceased to discharge. After remaining normal for twelve days the temperature rose again to 100°-10° F., stayed there for three days, with occasional remissions, then settled, and after a further three daysrose again to 100° F. The next day transient deviation of the eyes to the right, rigidity of the right side of the body, and bulging of the fontanelle were observed. -Lumbar puncture produced cerebrospinal fluid containing gram-negative bacilli culturally Pfeiffer’s bacillus. Prontosil rubrum one-sixth of a tablet was given twice daily, but the child died four days later.
daily
Jensen, Johnsrud and Nelson (1939) have
success-
treated a large series of compound fractures and dislocations by the implantation of crystalline sulphanilamide between the bone-ends in addition to the usual surgical measures of debridement,primary suture and immobilisation of the limb. In Germany Tonnis (1940) recommends the temporary packing of open cerebral wounds with a tampon steeped in Prontosil. By these means it is claimed that a high concentration of the sulphonamide is ensured locally during the earliest stages of the infection. It is important to know how the tissues may react to such treatment. As a corollary to a more extensive investigation of various antiseptics upon the rabbit’s brain (Russell and Falconer, 1940) we have made some further experiments with finely powdered sulphanilamide and sulphapyridine (M. & B. 693). In our earlier inB. 137). vestigation we also tested soluseptasine & Our object in these experiments was to ascertain the local histological effects of various bactericidal agents on the brain. We are not concerned here with the rationale of their use from a bacteriological point of view. Details of the operative procedures and the control experiments will be published elsewhere with the full account of our earlier work. In brief a decompression opening about 2 cm. bv 1 cm. was made over the dorsal surface of the left cerebrum, the dura reflected and the underlying brain treated as follows :-
fully
80LUSEPTASINE
(a) Pledgets of lintine soaked in a 3-3% solution in isotonic saline (pH 10) were laid on the surface for ten minutes after scarifying the arachnoid membrane in a In addition 0-1 c.cm. of the solution was few places. injected into the cortex with a finely graduated tuberculin syringe. The wound was then closed. The two rabbits so treated were killed after two and four days respectively. (6) The steps were repeated using a similar solution buffered to pH 7-4. .ResMs.—The leptomeninges and cortex at the site of exposure showed, on macroscopic and microscopic examination, no severer damage than was found in a control series using normal saline instead of the soluseptasine solution. The reaction to the injection was
FIG. 1—M. and B. 693. Particles in leptomeninges enclosed by cells four days after application (H. and E. x 100).
101 and
leptomeninges (fig. 2) resembled those obtained in using normal saline instead of the
earlier experiments test substance.
our
COMMENT
FIG. 2-Sulphanilamide. Site of exposure two days after operation. Shrinkage of a few neurones and oedema in superficial cortex. (H. and E. x 10 0).
of a narrow zone of cedematous tissue few polymorphonuclear leucocytes and degenerating neurones were present. Although the number of experiments was small it appeared that the buffered solution caused slightly less degeneration and inflammatory reaction than the unbuffered solution. This we would expect because control experiments using isotonic saline buffered to pH 10 had previously shown us that the superficial neurones underwent severer degeneration in this alkaline medium than with a strictly neutral solution.
slight, consisting in which
a
SULPHANILAMIDE AND
SULPHAPYRIDINJM
(a) In a similar operation on the rabbit’s brain, a thin layer of powdered sulphanilamide just sufficient to cover the area was sprinkled on the intact arachnoid membrane. It was estimated that about 14 mg. was used. The wound was then closed. (b) The experiment was repeated after scarifying the arachnoid membrane in five or six places to permit penetration into the leptomeningeal spaces. (c) Using a fine-bore (Harris) lumbar-puncture needle a small pellet of the powder weighing about 1 ing. was delivered into the depths of the cortex through a smaller opening in the skull. Three rabbits were used in each group. They were killed after one, two and four days respectively. A duplicate set of experiments was made with sulphapyridine.
facroscopM.—After 24hours no trace of the sulphanilamide was found in the wounds. Sulphapyridine persisted for two days but was not seen with the naked eye after four days. The exposed cortex was unaltered in all groups. The puncture wounds were identified as a thin red streak, the adjacent cortex being normal. Leptomeningeal injection and small areas of hsemorrhage were more conspicuous in the sulphapyridine experiments than in the sulphanilamide. Microscopic.-The appearances of the leptomeninges and cortex in the exposed areas confirmed our macroscopic observations except in one particular : a few particles of sulphanilamide were still present in the leptomeninges four days after operation in both groups 1 and 2. Similarly a few particles were found in the track Results.
of the puncture wound in the animals killed after two and four days. In agreement with the macroscopic findings many more particles of sulphapyridine persisted in the leptomeninges and were conspicuous after four days. In all instances the particles both of sulphanilamide and of sulphapyridine in this site were partly or wholly enclosed by a layer of foam-cells (fig. 1). In addition similar foam-cells and a few multinucleate giant-cells were present in the leptomeningeal spaces. Thus after two days a foreign-body reaction had already begun and was advanced by four days. Enclosure of the particles by foam-cell was less rapid in the puncture wounds : they were only partly enveloped after four days. In other respects the appearances of the cortex
Our experiments showed that no appreciable damage is sustained by the cortex and leptomeninges of the rabbit’s brain when exposed to soluseptasine (3-3%) or to finely powdered sulphanilamide and sulphapyridine. But if these substances are to be used locally in this way it appears preferable to use them in solution. The low solubility of sulphanilamide, and even more of sulphapyridine, results in the persistence in the wound of particles of the powder even when only small quantities are used. These particles excite a foreign-body giantcell reaction and are thus engulfed within a few days of the application. This must diminish if it does not nullify any further local action of the substance. If larger amounts of the powder are used the foreign-body reaction would be proportionately greater and might be expected to cause the undesirable local effects of a granuloma. If therefore circumstances dictate the use of a powder the smallest effective quantity should be applied. From our experiments we consider that the amount should be just sufficient to cover completely the exposed surface. Other things being equal sulphanilamide is more suitable than sulphapyridine since it is 1250 mg. will dissolve in 100 c.cm. of more soluble ; normal cerebrospinal fluid incubated for 14 hours at 35° C. ; the corresponding figure for sulphapyridine is 85 mg. (J. O’Brien, personal communication). Jensen and his colleagues recommended solid sulphanilamide since it enabled the highest possible concentration to be reached at the actual site of infection. If sulphapyridine, or large amounts of sulphanilamide, are to be used for the brain it would be preferable to apply them as saturated solutions in isotonic saline. Isotonic solutions of soluseptasine can also be used., SUMMARY
The local application of soluseptasine, solid sulphanilamide and solid sulphapyridine to the rabbit’s brain does not cause any appreciable damage to the tissues. Owing to their relative insolubility the quantities of dry substance used should be minimal. Sulphanilamide is preferable to sulphapyridine since it is more soluble. Excess of either substance will excite a foreign-body reaction which, in the brain at any rate, might entail unfortunate consequences. Solutions are preferable from a histological standpoint. Our thanks are due to Prof. W. E. Le Gros Clark who generously allowed us to make our experiments in the department of human anatomy ; to Mr. J. O’Brien of the Radcliffe Infirmary for biochemical help ; and to Mr. Chesterman of the
department of human anatomy
The expenses of this work
were
for the
microphotographs.
defrayed by
the Medical Research Council, whom
we
a
grant from
also thank.
REFERENCES
Jensen, N. K., Johnsrud, L. W. and Nelson, M. C. (1939) Surgery, 6, 1.
Russell, D. S. and Falconer, M. A. (1940) Proc. R. Soc. Med. 33, 494. Tönnis, W. (1940) Dtsch. med. Wschr., 66, 57.
VOLVULUS OF CÆCUM ASSOCIATED WITH REVERSED ROTATION OF MIDDLE GUT BY C. C. HOLMAN, M.B. Camb., F.R.C.S. SURGEON TO THE NORTHAMPTON GENERAL HOSPITAL
ON Jan. 4, 1940, I saw in consultation a woman, aged 66, who had had for three days symptoms suggesting intestinal obstruction. She was plump, with dry tongue
and distended abdomen. The right iliac fossa was tender and an indefinite tumour could be felt in the epigastrium. Under anesthesia a lump could be felt just to the right of the middle line below the umbilicus. At operation this lump was found to be twisted mesentery, and gentle manipulation delivered an immensely distended csecum. There was a volvulus of the ceecum and ascending colon, the latter being freely mobile. The volvulus was untwisted, and the caecum was emptied through a small Paul’s tube. The empty bowel appeared D 2
general condition of the patient ; the deflation of the blown-up abdomen is of secondary interest. REFERENCES
LOCAL EFFECTS OF SULPHONAMIDES ON THE RABBIT’S BRAIN
Tyrrell-Gray, H. (1936-37) Post-graduate Surgery, London, vol. i, pp. 1195, 1201. Robb, J. J. (1932), Brit. J. Surg. 19, 636. Cokkinis, A. J. (1936-37) Post-graduate Surgery, London, vol. i,
BY DOROTHY S.
AND
p. 1090. Dodd, H. (1938) Brit. med. J. 2, 624.
Flint, E.
R.
(1939) Post-grad.
RUSSELL, M.D. Lond.
WORKING FOR THE MEDICAL RESEARCH COUNCIL
MURRAY A. FALCONER, F.R.C.S.
med. J. 15, 234, 270.
(From
the
Nuffield Department of Surgery, Oxford University)
PFEIFFER’S-BACILLUS MENINGITIS TWO UNUSUAL
CASES
BY J. H. DOWDS, M.B., M.SC.
(From the Roan Antelope Hospital, Luanshya, Northern
Rhodesia) Ix the two following cases of Ffeiffer’s-bacillus meningitis the meningeal manifestations were apparently preceded by, and probably secondary to, subcutaneous abscesses containing Pfeiffer’s bacillus (Haemophillls tM.j!
other. CASE I.-A native boy, aged three or four months, was to hospital with a subcutaneous abscess of a few days’ duration over the right elbow. He was emaciated, his temperature was 100° F., and pulse-rate 120, regular, and of moderate volume. His chest and throat were clear, and there was no evidence of nervous trouble. The abscess was aspirated, less than 1 oz. of fluid brownish pus being drawn off ; this contained gram-negative bacilli having the cultural characteristics of Pfeiffer’s bacillus. Some bacilli showed
brought
bipolar staining. M. & B. 693, 0-16 g. followed by 0-08 g., was given thrice for five days, by which time the abscess had cleared up. The temperature remained at about 100° F. with occasional remissions for ten days, after which meningeal manifestations - heat retraction, transient deviation of the eyes to the left, and drawing up of the legs-were observed for the first time, though the nervous system had been examined daily. The fontanelle was not tense, and lumbar puncture yielded only a couple of drops of thick turbid fluid containing bacilli resembling those obtained from the abscess and culturally Pfeiffer’s bacillus. Treatment with M. & B. 693 was started again, 0-25 g. being given, followed by 0-12 g. thrice daily. A white-cell count done at this time showed 3900 leucocytes, of which 33 per cent. were lymphocytes, 15 per cent. monocytes, and the remaining 52 per cent. polymorphs (juvenile forms 28 per cent., stab forms 6 per cent., and segmented forms 18 per cent.). No myelocytes and no eosinophils were seen. The pulse became rapid, and the temperature dropped below normal, where it remained till the child died. At necropsy thick yellow pus was found over the vertex of the cerebrum, its base, and the brain stem. There was slight congestion at the bases of the lungs, and the kidneys were pale and fatty. CASE 2.-A native child, aged three and a half months, was admitted to hospital in a fairly healthy condition apart from swellings on the left arm and buttock. The swelling on the buttock was incised and pus evacuated containing gramnegative bacilli culturally identical with Pfeiffer’s bacillus. No signs or symptoms suggesting involvement of the central nervous system were noted. Treatment with M. & B. 693 was carried out as in case 1. The temperature, which was 100° F. on admission, settled in three days under treatment, the swelling on the arm cleared up spontaneously, and the buttock ceased to discharge. After remaining normal for twelve days the temperature rose again to 100°-10° F., stayed there for three days, with occasional remissions, then settled, and after a further three daysrose again to 100° F. The next day transient deviation of the eyes to the right, rigidity of the right side of the body, and bulging of the fontanelle were observed. -Lumbar puncture produced cerebrospinal fluid containing gram-negative bacilli culturally Pfeiffer’s bacillus. Prontosil rubrum one-sixth of a tablet was given twice daily, but the child died four days later.
daily
Jensen, Johnsrud and Nelson (1939) have
success-
treated a large series of compound fractures and dislocations by the implantation of crystalline sulphanilamide between the bone-ends in addition to the usual surgical measures of debridement,primary suture and immobilisation of the limb. In Germany Tonnis (1940) recommends the temporary packing of open cerebral wounds with a tampon steeped in Prontosil. By these means it is claimed that a high concentration of the sulphonamide is ensured locally during the earliest stages of the infection. It is important to know how the tissues may react to such treatment. As a corollary to a more extensive investigation of various antiseptics upon the rabbit’s brain (Russell and Falconer, 1940) we have made some further experiments with finely powdered sulphanilamide and sulphapyridine (M. & B. 693). In our earlier inB. 137). vestigation we also tested soluseptasine & Our object in these experiments was to ascertain the local histological effects of various bactericidal agents on the brain. We are not concerned here with the rationale of their use from a bacteriological point of view. Details of the operative procedures and the control experiments will be published elsewhere with the full account of our earlier work. In brief a decompression opening about 2 cm. bv 1 cm. was made over the dorsal surface of the left cerebrum, the dura reflected and the underlying brain treated as follows :-
fully
80LUSEPTASINE
(a) Pledgets of lintine soaked in a 3-3% solution in isotonic saline (pH 10) were laid on the surface for ten minutes after scarifying the arachnoid membrane in a In addition 0-1 c.cm. of the solution was few places. injected into the cortex with a finely graduated tuberculin syringe. The wound was then closed. The two rabbits so treated were killed after two and four days respectively. (6) The steps were repeated using a similar solution buffered to pH 7-4. .ResMs.—The leptomeninges and cortex at the site of exposure showed, on macroscopic and microscopic examination, no severer damage than was found in a control series using normal saline instead of the soluseptasine solution. The reaction to the injection was
FIG. 1—M. and B. 693. Particles in leptomeninges enclosed by cells four days after application (H. and E. x 100).
101 and
leptomeninges (fig. 2) resembled those obtained in using normal saline instead of the
earlier experiments test substance.
our
COMMENT
FIG. 2-Sulphanilamide. Site of exposure two days after operation. Shrinkage of a few neurones and oedema in superficial cortex. (H. and E. x 10 0).
of a narrow zone of cedematous tissue few polymorphonuclear leucocytes and degenerating neurones were present. Although the number of experiments was small it appeared that the buffered solution caused slightly less degeneration and inflammatory reaction than the unbuffered solution. This we would expect because control experiments using isotonic saline buffered to pH 10 had previously shown us that the superficial neurones underwent severer degeneration in this alkaline medium than with a strictly neutral solution.
slight, consisting in which
a
SULPHANILAMIDE AND
SULPHAPYRIDINJM
(a) In a similar operation on the rabbit’s brain, a thin layer of powdered sulphanilamide just sufficient to cover the area was sprinkled on the intact arachnoid membrane. It was estimated that about 14 mg. was used. The wound was then closed. (b) The experiment was repeated after scarifying the arachnoid membrane in five or six places to permit penetration into the leptomeningeal spaces. (c) Using a fine-bore (Harris) lumbar-puncture needle a small pellet of the powder weighing about 1 ing. was delivered into the depths of the cortex through a smaller opening in the skull. Three rabbits were used in each group. They were killed after one, two and four days respectively. A duplicate set of experiments was made with sulphapyridine.
facroscopM.—After 24hours no trace of the sulphanilamide was found in the wounds. Sulphapyridine persisted for two days but was not seen with the naked eye after four days. The exposed cortex was unaltered in all groups. The puncture wounds were identified as a thin red streak, the adjacent cortex being normal. Leptomeningeal injection and small areas of hsemorrhage were more conspicuous in the sulphapyridine experiments than in the sulphanilamide. Microscopic.-The appearances of the leptomeninges and cortex in the exposed areas confirmed our macroscopic observations except in one particular : a few particles of sulphanilamide were still present in the leptomeninges four days after operation in both groups 1 and 2. Similarly a few particles were found in the track Results.
of the puncture wound in the animals killed after two and four days. In agreement with the macroscopic findings many more particles of sulphapyridine persisted in the leptomeninges and were conspicuous after four days. In all instances the particles both of sulphanilamide and of sulphapyridine in this site were partly or wholly enclosed by a layer of foam-cells (fig. 1). In addition similar foam-cells and a few multinucleate giant-cells were present in the leptomeningeal spaces. Thus after two days a foreign-body reaction had already begun and was advanced by four days. Enclosure of the particles by foam-cell was less rapid in the puncture wounds : they were only partly enveloped after four days. In other respects the appearances of the cortex
Our experiments showed that no appreciable damage is sustained by the cortex and leptomeninges of the rabbit’s brain when exposed to soluseptasine (3-3%) or to finely powdered sulphanilamide and sulphapyridine. But if these substances are to be used locally in this way it appears preferable to use them in solution. The low solubility of sulphanilamide, and even more of sulphapyridine, results in the persistence in the wound of particles of the powder even when only small quantities are used. These particles excite a foreign-body giantcell reaction and are thus engulfed within a few days of the application. This must diminish if it does not nullify any further local action of the substance. If larger amounts of the powder are used the foreign-body reaction would be proportionately greater and might be expected to cause the undesirable local effects of a granuloma. If therefore circumstances dictate the use of a powder the smallest effective quantity should be applied. From our experiments we consider that the amount should be just sufficient to cover completely the exposed surface. Other things being equal sulphanilamide is more suitable than sulphapyridine since it is 1250 mg. will dissolve in 100 c.cm. of more soluble ; normal cerebrospinal fluid incubated for 14 hours at 35° C. ; the corresponding figure for sulphapyridine is 85 mg. (J. O’Brien, personal communication). Jensen and his colleagues recommended solid sulphanilamide since it enabled the highest possible concentration to be reached at the actual site of infection. If sulphapyridine, or large amounts of sulphanilamide, are to be used for the brain it would be preferable to apply them as saturated solutions in isotonic saline. Isotonic solutions of soluseptasine can also be used., SUMMARY
The local application of soluseptasine, solid sulphanilamide and solid sulphapyridine to the rabbit’s brain does not cause any appreciable damage to the tissues. Owing to their relative insolubility the quantities of dry substance used should be minimal. Sulphanilamide is preferable to sulphapyridine since it is more soluble. Excess of either substance will excite a foreign-body reaction which, in the brain at any rate, might entail unfortunate consequences. Solutions are preferable from a histological standpoint. Our thanks are due to Prof. W. E. Le Gros Clark who generously allowed us to make our experiments in the department of human anatomy ; to Mr. J. O’Brien of the Radcliffe Infirmary for biochemical help ; and to Mr. Chesterman of the
department of human anatomy
The expenses of this work
were
for the
microphotographs.
defrayed by
the Medical Research Council, whom
we
a
grant from
also thank.
REFERENCES
Jensen, N. K., Johnsrud, L. W. and Nelson, M. C. (1939) Surgery, 6, 1.
Russell, D. S. and Falconer, M. A. (1940) Proc. R. Soc. Med. 33, 494. Tönnis, W. (1940) Dtsch. med. Wschr., 66, 57.
VOLVULUS OF CÆCUM ASSOCIATED WITH REVERSED ROTATION OF MIDDLE GUT BY C. C. HOLMAN, M.B. Camb., F.R.C.S. SURGEON TO THE NORTHAMPTON GENERAL HOSPITAL
ON Jan. 4, 1940, I saw in consultation a woman, aged 66, who had had for three days symptoms suggesting intestinal obstruction. She was plump, with dry tongue
and distended abdomen. The right iliac fossa was tender and an indefinite tumour could be felt in the epigastrium. Under anesthesia a lump could be felt just to the right of the middle line below the umbilicus. At operation this lump was found to be twisted mesentery, and gentle manipulation delivered an immensely distended csecum. There was a volvulus of the ceecum and ascending colon, the latter being freely mobile. The volvulus was untwisted, and the caecum was emptied through a small Paul’s tube. The empty bowel appeared D 2