“1. The development of suppuration on the soft parts caused by
bacteriae cannot be prevented, even if sulfanilamides are
applied immediately, locally, or internally.
“2. It could not be proved that the course of an inflammatory
illness caused by aerobic organisms on abscesses and phlegmons
of the limbs was influenced by sulfanilamides. We were of the
impression that combined gas gangrene therapy took a milder
course under the influence of sulfanilamides.
“3. Surgical measures are indispensable for a successful
treatment of inflammations.”
_Additional Remarks_
The sprinkling of sulfanilamide powder on wounds can be injurious, if,
by so doing, the fundamentals of surgery are infringed, if, for
instance, the powder basis is not dissolved by the tissue fluids, and if
the discharge of secretions is hampered by coagulation. The wounds
treated with sulfanilamide powder show a slight tendency to exudation.
_Hypothesis of Functions_
The inflammation on the mesodermal soft parts shows a tendency towards
necrosis at an early stage. The necrosis is the seat of the bacterial
culture. Its surroundings show thrombosed vessels. Access to it by
chemo-therapeutic reagents is very difficult.
* * * * *
_Directives for the Application of Sulfanilamides_
_Experiments_ (_Gebhardt-Fischer_) showed the following results: Even
the immediate internal and external application of sulfanilamide
preparations cannot prevent a suppuration of the soft parts due to
ordinary suppurative organisms. It could not be proved that the course
of the inflammatory disease caused by anaerobions is influenced by
sulfanilamides. The sulfanilamides seemed to have an easing effect on
the course of combined gangrene therapy.
_Disorders caused by sulfanilamides_ (_Randerath_) are relatively rare.
They occur directly as liver disorders including acute yellow liver
atrophy, as kidney disorders, and as agranulocytosis. Therefore, as far
as is possible under front-line conditions, the white and red blood
count should be controlled. The decrease of the body temperature caused
by an infection of the central regulatory system may be looked upon as
an indirect disorder, so that the temperature curve permits no
conclusions as to the development of the wound infection. Furthermore,
local powder treatment may lead to an occasional increase in the depth
of the wound infection. Direct injury to the tissue at the spot where
the preparations were applied was not observed.
_The endolumbal application of the sulfanilamides_ (_Mueller_) must also
be rejected for the treatment of meningitis, since it leads to serious
disturbances in the region of the spinal cord and may result in
paralysis.
_The clinical discourse_ (_Frey_) emphasized the decrease of optimistic
and the increase of critical opinions. The clinical doctor considers the
principal disorders to be anorexia, nausea, and increasing exhaustion.
Early application in the wound itself is essential for the efficacy. The
enteral or parenteral inducing of sulfanilamide drugs cannot prevent
wound infections, but can favorably influence its course.
_The following rules for practice therefore result_: All surface wounds,
that is, grazing shot wounds, sulcus-shaped wounds and large gaping
wounds of the soft parts should be sprinkled as soon as possible with
sulfanilamide powder. The powder treatment is of no use if the depths of
the wound are not reached. It is ineffective to powder the small wounds
caused by the penetration and exit of the bullet. The powdering of the
skin is senseless and may cause eczema. Deeper wounds must be treated in
the quickest and most thorough manner. After this, the wound can be
additionally treated with sulfanilamide powder which must reach the
deepest cavities. It is not advisable to powder granulating wounds.
If the powder treatment cannot be applied during the first hours or does
not seem to suffice, a pororal application of sulfanilamides should take
its place or be performed supplementarily. Front-line conditions will
not always allow intravenous injections. According to the danger of a
wound infection, the wound should be treated for a short time with large
doses of sulfanilamides (6-10 grams during 3-4 days, not more than a
total of 50 grams). On the whole, small doses are insufficient and
therefore have no influence on the course of an infection, but if
applied too long they may be injurious. Suitable preparations are
preferably eleudron, cibazol, and globucide. If possible, the treatment
should be applied by a medical officer.
Wounds endangered by gas oedema—and this means all large and deep
muscle wounds—should, in addition to the local and oral treatment with
sulfanilamide, also be treated with gangrene serum. At subsequent
operations, for example resection of the ribs, empyema of the chest,
secondary sutures, and late amputations, the new wound caused by the
operation may be powdered adequately with sulfanilamides when bleeding
has stopped.
The thoroughness of the surgical wound treatment should in no way be
lessened even by the additional application of sulfanilamides.
Abdominal gunshot wounds can also be treated with sulfanilamide powder
(about one tablespoon) or the sulfanilamide may be induced into the
abdominal cavity in the form of an emulsion.