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ANTI-BIOTICS SALVARSAN 606 From 1906, Bertheim and his colleagues synthesized over 600 arsenic compounds(1), which Paul Erlich, a German chemist screened as potential treatment for syphilis. The results showed variance in activity, but none were considered to be useful(2). Sacachiro Hata, at the Kitasato Institute, Tokyo, Japan, developed a means of infecting rabbits with syphilis, and in the Spring of 1909 joined Ehrlich and was asked to test every arsenic compound that had been synthesized by Bernheim during the previous three years(3). The compounds were tested and re-tested for months, with thousands of animals being used(4). Hata found that the 592nd compound he tested was effective in inhibiting syphilis spirochaete but was also too toxic. This compound was purified and made more soluble - resulting in compound 606 (ie the 606th to be tested)(5). It is worth noting that this particular compound had been recorded by one of Ehrlich`s assistants as "negative" but when Hata re-tested it, he found that active in rabbits against the organism which causes syphilis(6). Following the animal experiments, samples of "606" were sent to Prof Julius Iversen of Obuchow Hospital, St Petersburg. As Treponema pallidum - the organism which causes syphilis - was similar to Borella recurrentis - which causes a disease transmitted by lice - Iversen treated patients relapsing with the latter condition and claimed successful use of "606". Prof Alt also received samples of "606" and two assistants volunteered to receive injections of the compound, but Alt refused. After he spent three months testing it on dogs, Alt finally allowed the two assistants to receive injections. It was only after the volunteers had received their injections that "606" was given to syphilitic patients. Others also conducted trials in human patients. In April 1910, at a Congress of Internal Medicine, Ehrlich announced the results of the clinical trails. With support from the delegates and attention of the world`s press, doctors and patients began demanding "606", but Ehrlich restricted supplies to only a small selected number of colleagues. It was not until the end of 1910, with the drug company establishing a plant for production that "606" was marketed as Salvarsan , and later given the approved name arsphenamine(7). But, clinically, Salvarsan was so dangerous that it could only be given every seven days by intraveneous injection with extreme caution - because if any of the compound escaped from the vein of the patient, necrosis could develop, leading to the loss of the patient`s arm. Other adverse reactions included rashes, and liver damage leading to jaundice. Some expressed doubts as to Salvarsan`s value as a treatment of syphilis, and some medical opinions questioned whether it was a valid substitute for mercury - a view shared in the `Journal of the American Medical Association` in 1914(8). An estimated 274 people died as a result of Salvarsan(9). 1. Sneader,W. Drug Discovery. John Wiley & Sons. 1985. 2. Dixon,B. Beyond the Magic Bullet. George Allen & Unwin. 1978. 3. Sneader,W. Drug Discovery. John Wiley & Sons. 1985. 4. Marquardt,M. cited in ibid. 5. Wainwright,M. Miracle Cure.Basil Blackwell. 1990. 6. Dixon,B. Beyond the Magic Bulet. George Aleen & Unwin. 1978. 7. Sneader,W. drug Discovery. John Wiley & Sons. 1985. 8. Wainwright,M. Miracle Cure. Basil Blackwell. 1990. 9. Hadwen,WR. The Difficulties of Dr Deguerre. CW Daniel & Co. 1926. |
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PRONTOSIL Paul Gelmo observed that sulphonamide combined with wool and silk(1) and in 1908 he synthesized a chemical derivative of it(2). During preparation of azo dyes for a German dye company, I G Farbenindustrie, Heinrich Hoerlein found that adding sulphonamide increased the dye`s ability to bind with wool(2) and in 1909, he patented sulphanilamide(3) but never considered the compound as an antibacterial agent(4). In 1915, at the Rockerfeller Institute,New York, Charles Heidelberger found that a sulphanilamide derivitive, ethylhydrocuprein, killed bacteria in vitro but when injected into mice was more lethal than the induced disease(4). Eleven years later, Julius Morgenroth found that the chemical damaged the optical nerve of mice experimentally infected with pneumonia(5). Nevertheless, the compound was marketed to treat pneumonia but some patients were blinded by it. When Morgenroth examined analogues of the compound, he found some were effective against various bacteria, but all were considered too toxic for clinical use. After Morgenroth`s death, Schnitzer was offered a position at Hoechst Dyeworks, administering hundred of compounds to mice infected with streptococci and, by 1926, found that the nitro group of compounds could control infection in the mice - a nitro-acridine was effective against streptococci in animals, but was considered not to be potent enough for clinical use(6). In 1927, Gerhard Domagk was appointed Director of the Institute of Experimental Pathology at I G F, where he developed his own method for testing compounds - by screening the effectiveness in mice that had been inoculated with streptoccocus pyogenes (a highly virulent strain of haemolytic streptococcus, which causes tonsolitis and scarlet fever in humans). Domagk isolated this particular bacterial strain from a patient who had died from septicaemia and increased its virulence, passing it through mice. Eventually, he reached a level where all of the injected mice died within a day, and reasoned that only a very effective treatment would have any effect on this. Domagk tested substances already known to be antibacterials and "confirmed" the previous findings of others, and dyes, previously examined in culture, which were ineffective. He found that sulphonamide derivatives screened in mice showed a positive effect. A large range of sulphonamide dyes were then synthesized in 1932 and given to Domagk for him to evaluate(6). One of the sulphonamide-containing azo dyes prepared was a red compound, Prontosil(7). In Christmas week 1932, Domagk isolated haemolytic streptococci from a human patient with sepsis. He diluted the bacteria in cultures and intraveneously infected 26 mice(8) - 12 treated with the dye, Prontosil Rubrum, "survived" haemolytic infection; 13 out of 14 untreated mice died from infection within 14 days(9). Although in his subsequent paper, Domagk only mentioned using mice in his experiments of December 1932, he, later, used Prontosil in rabbits experimentally infected with streptococci(10). Early in 1933, Dr Robert Foertser had a 10 month old patient who was dying of staphylococci septicaemia, when Hans Schreus, a professor at Dusseldorf Medical School, remembered Hoerlein mentioning a new dye which was effective against streptococci in animals(11). Schreus approached I G F and was told the new dye was only intended for streptococci infections - indicating that the drug had only been tested against streptococci infections and not against staphylococci. I G F supplied Schreus with some tablets, which were handed to Foerster, who began treating his patient. The boy improved and was discharged from hospital(12). Thus Prontosil was used clinically for staphylococcal infection before Domagk tested it against this bacterial infection, experimentally-induced, in rabbits. He found the clinical results were not as good or as regular as those in rabbits with experimental streptococcal infections(13). Further to this, when Levadti and Vaisman investigated Prontosil in 1935, they could not confirm Domgk`s findings of Prontosil`s curative effect in experimental staphylococcal infections in rabbits. But the confusion from results of animal experiments did not end there. Levadti and Vaisman also reported Prontosil was specific for streptococcal infections in animals, but had no curative effect in certain other experimentally-induced bacterial infections in mice. They added that Prontosil was effective in mice infected with streptococci of low virulence(14) - but in the same issue of the journal which carried their paper, Nitti and Bovet at Fourneau`s laboratory in the Pasteur Institute, Paris, reported that Prontosil was ineffective in control of experimental infections in mice produced by streptococci of low viruence. From their observations of their own experiments, they concluded that in treating experimental infections produced by injections of streptococci of high virulence the drug gave inconsistent results(15) - in direct contrast to the results of the experiments by Levadti and Vaisman. In his original paper, of Febrary 1935, Domagk considered Prontosil was non-toxic for mice, rabbits and cats - but he had failed to find the lethal dose as the animals vomited larger doses, and in the same paper, he stated that Prontosil was ineffective against experimental infections of pneumocci in animals(16) but in his second paper (later in 1935), he announced that Prontosil was definitely effective in experimental type III pneumococcal infections(17). In February 1935 - the month in which Domagk`s first paper appeared - he used Prontosil Rubrum to treat his daughter, who had developed speticaemia after pricking her finger with a needle(18). Leonard Colebrook, a bacteriologist at Queen Charlotte`s Maternity Hospital, London, had read Domagk`s paper but had not been impressed(19) and neither was one of his team, Ronald Hare(20). After hearing about Prontosil at a lecture in October 1935, Colebrook considered its possible use in treating human patients with puerperal fever(21). He requested and finally obtained samples(22) but his first patient was to be Hare, who, in January 1936, pricked his finger on glass infected with streptococci and developed a rapidly spreading infection. Colebrook gave Hare Prontosil by mouth and by injection(23). Hare`s first reaction to the drug was for his body to turn bright pink(24) then, as he was to later record, he did not know if he was dying from the infection or the drug(25) - but the clinical trial was deemed a "success". Colebrook`s next patient was a technician, W R Maxted, who had contracted severe tonsillitis from experimenting with streptococci. When Maxted was given Prontosil, he suffered stomach pain, intense internal heat and was violently sick - but eventually recovered(26). In 1936, Colebrook used Prontosil Rubrum in a clinical trial of 38 women with puerperal fever - 3 died. He treated a futher 26 - with no deaths(27). Clinical experience had shown the way. Meanwhile, Eleanor Roosevelt, wife of the US President, asked George Tobey, of Massachusettes General Hospital to treat their son who was dying from streptococci infection. Tobey administered Prontosil and the patient recovered(28). refs 1. Kohn,A. Fortunes or Failure - Missed Opportunities & Chance Discoveries. Basil Blackwell. 1989. 2. Sneader,W. Drug Discovery. John Wiley & Sons. 1985. 3. Horlein,H. patent no DRP 226239. 1909. 4. Kohn,A. Fortunes or Failure - Missed Opportunities & Chance Discoveries. Basil Blackwell. 1989. 5. Williams,TL. Howard Florey - Penicillin and After. Oxford Uni Press. 1984. 6. Sneader,W. Drug Discovery. John Wiley & Sons. 1985. 7. Macfarlane,G. Alexander Fleming - the Man & the Myth. Catto & Windus. 1984. 8. Domagk,G. Duetsch Med Wchnschr. vol 61. 1935. 9. Sneader,W. Drug Discovery. John Wiley & Sons. 1985. 10. Domagk,G. Duetsch Med Wchnschr. vol 61. 1935. 11. Robert,RM. Serendipity - Accidental Discoveries in Science. John Wiley & Sons. 1989. 12. Sneader,W. Drug Discovery. John Wiley & Sons. 1985. 13. Domagk,G. Duetsch Med Wchschr. vol 61. 1935. 14. Levadti,C. Vaisman,A. Compt rend Soc de Biol. vol 119. 1935. 15. Nitti,F. Bovet,D. Compt rend Soc de Biol. vol 119. 1935. 16. Domagk,G. Duetsch Med Wchschr. vol 61. 1935. 17. Domagk,G. Ang Chem. vol 48. 1935. 18. Sneader,W. Drug Discovery. John Wiley & Sons. 1985. 19. Macfarlane,G. Alexander Flening - the Man and the Myth. Catto & Windus. 1984. 20. Hare,R. quoted in Wainwright,M. Miracle Cure. Basil Blackwell. 1990. 21. Macfarlane,G. Alexander Fleming - the Man and the Myth. Catto & Windus. 1984. 22. Sneader,W. Drug Discovery. John Wiley & Sons. 1985. 23. Macfarlane,G. Alexander Fleming - the Man and the Myth. Catto & Windus. 1984. 24. Wainwright,M. Miracle Cure. Basil Blackwell. 1990. 25. Hare,R. The Birth of Penicillin. George Allen & Unwin. 1990. 26. Wainwright,G. Miracle Cure. Basil Blackwell. 1990. 27. Sneader,W. Drug Discovery. John Wiley & Sons. 1985. 28. Roberts,RM. Serendipity - Accidnetal Discoveries in Science. John Wiley & Sons. 1989. |
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SULPHALINAMIDE At the Pasteur Institute, the Trefouels learned of the German studies and, under direction of Fourneau, began examining compounds closely related in chemical structure to Prontosil(1). Fourneau synthesized a sulphonamide, which was given the name sulphanilamide(2). Nitti and Bovet showed, in 1935, that sulphanilamide gave signs of protection in rabbits infected with an animal strain of haemolytic streptococci(3), but Gay and Clark, in 1937, found that in toxicity studies, rabbits gave inconsistent responses and that some rabbits died from doses of sulphanilamide which were well substantiated in other rabbits(4), and McMahn reported, in 1938, of toxic reactions in 75% of the rabbits he had used in his experiments(5). Buttle, in 1936, reported that sulphanilamide had little activity against pneumococci infections in mice(6), but a year later, reported that it prolonged the life of mice with experimental infections of types I and II pneumococci(7). Rosenthal reported in 1937 that sulphanilamide had a marked curative effect in rats infected with types I, II, and III pneumococci infections, and results of experiments in rabbits infected with one of the three types of pneumococci infections, closely resembled the results seen in mice(8), but Gross and Cooper reported, in 1937, that the treatment only modified the course of infection of type III pneumococci in rats. When Gross and Cooper conducted further experiments, they found that in rats with type II pneumococci infection, less than 75% "survived" when treated with sulphanilamide(9). Buttle reported, in 1937, that mice infected with a virulent strain of bovine staphylococcus lived for up to 12 days when given sulphanilamide(10), but a year later, Parish - who had worked with Buttle - reported that although repeated doses "protected" mice against multiple lethal doses of virulent staphylococci, the organisms persisted in the tissues of infected mice causing abscesses in the liver and spleen(11). In toxicity studies, Barlow reported, in 1937, that young rats given sulphanilamide in doses of 0.25gm/kg (body weight) showed no difference in growth rates compared to rats not given the drug(12). Gay and Clark reported, in 1939, that some rabbits died from doses which other rabbits tolerated(13). Molitor and Robinson reported that 2 gm/kg retarded growth in rats, but this quantity was lethal in dogs and rabbits(14). In 1936, during the time of the conflicting results of animal experiments, investigators discovered, using cultures of haemolytic streptococcus, staphylococcus, pneumococcus and other bacteria, that sulphanilamide was active in vitro(15). In 1937, Marshall, Cutting and Emerson found that up to 20% of the sulphanilamide administered to human patients became inactivated by a change in solubility. From this, they went on to study metabolism and distribution of the drug in humans(16). Sulphonamide derivatives continued to be synthesized, tested in animals, and trailled in humans. By 1947, over 5000 sulphonamdes had been produced. Some were better than sulphanilamide against certain infections but not all were effective(17). Sulphonamides continued to be used, but increasing bacterial resistance and availability of more effective and less toxic antibiotics led to a significant decrease in the use of the sulphonamides(18). refs 1. Roberts,RM. Serendipity - Accidnetal Discoveries in Science. John Wiley & Sons. 1989. 1. Sneader,W. Drug Discovery. John Wiley & Sons. 1985. 3. Trefouel,J et al. Comp rend Soc de Biol. vol 120. 1935. 4. Gay,FP. Clark,AR. J Exp Med. vol 66. 1937. 5. McMahon,BJ. Arch Otolargyng. vol 28. 1938. 6. Buttle,GAH et al. Lancet. 1936. 7. Buttle,GAH et al. Lancet. 1937. 8. Rosenthal,SM et al. Public Health report. vol 52. 1937. 9. Gross,P. Cooper,FB. proc soc Exp Biol & Med. 1937. 10. Buttle,GAH et al. Lancet. 1937. 11. Parish,HJ. British Medical Journal. 1937. 12. Barlow,OW. Proc Soc Exp Biol & med. 1937. 13. Gay,FP. Clark,AR. J Exp Med. vol 66. 1937. 14. Molitor,H. Robinson,H. in Long,PH. Bliss,EA. Clinical & Exp Use of Sulfanilamide... Macmillan Co. 1939. 15. Long,PH. Bliss,EA. Clinical & Experimental Use of Sulfanilamide... Macmillan Co. 1939. 16. Marshall,EK Jnr et al. JAMA. 1938. 17. Roberts,RM. Serendipity - Accidnetal Discoveries in Science. John Wiley & Sons. 1989. 18. Parish,P. Medicines - A Guide for Everybody. Penguin. 1987. |
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STREPTOMYCIN In 1944, Prof Selman Waksman, Schatz and Bugie studied micro-organisms in soil samples and discovered the antibiotic activity of Streptomyces griseus - a mould-like bacteria(1). Waksman found that streptomycin was active against various bacteria, but - as he recalled - "No absolute values can be given for the sensitivity of a given organism to streptomycin. This depends not only upon the species but also upon the strain, and upon the composition of the medium in which it is tested". From animal studies, Waksman concluded that streptomycin was the most effective agent for the treatment of tuberculosis which had been studied so far, but he was also aware of the unreliability of animal experiments - as he wrote "To produce toxic manifestations of streptomycin in animals, it is necessary to administer either extraordinary large amounts of the pure material or smaller amounts of certain impure preparations. No correlation was obtained between the acute toxicity of different lots of experimental animals and clinical tolerance in human beings. The behaviour of the material in [hu]man[s] cannot, therefore, be foretold if anti-bacterial potency alone is assumed to be the criteria of purity"(2). Soon after streptomycin entered clinical use, W H Feldman reported in the `British Medical Journal` in 1948 "Although the administration of streptomycin to tuberculous human beings usually provokes certain objective signs to toxicity of varying severity, this drug is well tolerated by guinea pigs and mice within the therapeutic levels"(3). A medical dictionary, published in the 1980s, notes that "Streptomycin was frequently used to treat tuberculosis, but the high incidences of undesirable side effects and the threat of bacterial resistance to it, means that it s no longer used alone"(4). refs 1. Frobisher,M. Fundamentals of Microbiology. 8th ed. WB Saunders & Co. 1968. 2. Waksman,S. J of the History of Medicine. vol 6. 1951. 3. Feldman,WH. British Medical Journal. 17 Jan 1948. 4. Fisher,RB. Christie,GA. A Dictionary of Drugs. Paladin. 1982. |
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PENICILLIN In 1928, a spore from one of the moulds in C La Touche`s room drifted through the air, up to the floor above, to Alexander Fleming`s lab, and settled in a petri dish containing agar impregnated with staphylococci bacteria. Fleming left the culture plate on his bench. A cool spell of weather encouraged the mould to grow and produce enough penicillin to kill the bacteria(1). By culture methods, Fleming found penicillin killed streptococci, pneumococci, meningococci, gonococci, and diphtheria bacilli(2). Fleming tested pencillin in one mouse and one rabbit - it was non-toxic(3) but was rapidly excreted in the urine of the mouse, suggesting, it would be of little clinical use(4). Fleming did not give penicillin to infected mice(5). RDS claims that "Had Fleming himself carried out a simple, well-established animal test, the mouse protection test, then the potential of his discovery might have been realized ten years earlier"(6). In 1935. Domagk claimed a 100% success rate by the mouse protection test when Prontosil was injected against haemolytic streptococci bacteria(7). Others found Prontosil had no curative effect against other experimentally-induced bacteria infections in mice(8) - the mouse protection test showed Prontosil was ineffective against low virulence strains of haemolytic streptococci bacteria and gave inconsistent results against high virulence strains(9). Domagk`s "success" had been due to the short duration of his experiments in mice(10). In 1937, Domagk said Prontosil was effective against staphylococcal infections, but only in a short period of time(11). Others noted "staphylococcal infections in mice do not as a rule, give the sharp, clear-cut results that are obtained in streptococcal infections in these animals"(12). From his experiments on one mouse and one rabbit, Fleming concluded penicillin required four hours to act, but his research student, S R Craddock, found that when penicillin was injected into a rabbit it disappeared in 30 minutes(13) - two experimenters using the same species with two different results! Craddock grew penicillin mould in milk and tried eating some and found it was non-toxic(14). When one of Fleming`s other assistants developed conjunctivitis, it was treated with penicillin "juice" and cleared up immediately. After this clinical finding, C G Paine, at Sheffield Royal Infirmary, obtained some penicillin culture from Fleming and successfully treated a number of patients who had conjunctivitis(15). In the 1930s, Ernst Chain and N G Heatley, using biochemical techniques, managed to isolate purified penicillin and tested it in culture plates of various bacteria. Chain did not hold a licence to experiment on animals, so J M Barnes injected the purified penicillin into two mice and found it was non-toxic - preceded by Craddock tasting it. Howard Florey was working with Chain and, as he too held a licence to experiment on animals, was annoyed at being overlooked so repeated the test with penicillin on another mouse. Over the next few months, Florey tried penicillin in more mice, rats, rabbits and cats and announced that penicillin was excreted, unchanged in the urine in two hours or less(16) - not only preceded in experiments by Fleming, Craddock, Barnes, but another set of results. Fleming had found that penicillin was excreted too rapidly in the urine of the mouse to be of clinical use and from his test in a rabbit would take four hours to act, Craddock had said that penicillin injected into rabbits disappeared in 30 minutes, and now Florey maintained that penicillin was excreted unchanged in the urine of animals in less than two hours! On 25 May 1940, Florey injected eight mice with lethal doses of streptococci bacilli and injected penicillin into four of the mice, which lived two days longer than the four mice which had not been given penicillin; and a year later, he injected penicillin into a human patient who was dying of cancer to study the toxicity and found it was non-toxic(16). On 5 Aug 1942, a friend of Fleming`s was dying of streptococcal meningitis at St Mary`s Hospital, London. Florey took Fleming some pencillin and showed him how to use it. Fleming injected his friend with the penicillin but as it would not cross from the blood into the cerebrospinal fluid he decided to try injecting penicillin directly into the spine and phoned Florey for advise. Florey injected it into the spine of a rabbit to see if was safe(17). But Florey reported in his own notebook - on 13 August - that spinal injections of penicillin into the rabbit had fatal results(18). Fortunately, before the results of the failure in the rabbit were known, Fleming`s friend had been given the spinal injection of penicillin and improved(19). Florey stated in 1953 "Mice were used in the initial toxicity tests because of their small size which economized the precious material but what a lucky chance it was, for in this respect [hu]man[s] [are] like the mouse and not the guinea pig. If we had used guinea pigs exclusively we should have said that penicillin was toxic, and we probably should not have proceeded to try and overcome the difficulties of producing the substance for trial in [hu]man[s]"(20). RDS claims toxic dosage in guinea pigs was described by Hamre in 1943. Subsequent results showed a daily dosage of 40,000 units per kg killed 70% of the guinea pigs in 3 days(21). (NB: 1600 units is equal to 1 mg of penicillin(22), so 40,000 units = 25mg). In humans, the dosage of penicillin is up to 600 mg, 3 three times daily(23). Expressed as mg/Kg/daily (penicillin in mg, per kg body weight, per day), this translates to: - guinea pigs: 25mg/kg/daily = killed 70% given in 3 days. - 60kg person: 30mg/kg/daily = curative dosage given in 3 days. refs 1. Sneader,W. Drug Discovery. John Wiley & Sons. 1985. 2. Macfarlane,G. Alexander Fleming: the man and the myth. Hogarth Press. 1984 3. Macfarlane,G. Howard Florey... 4. Howie,J. BMJ. vol 293. 1986. 5. Sneader,W. Drug Discovery. John Wiley & Sons. 1985. 6. RDS website. 1995 (copy with SAV) 7. Domagk,G. 1935. cited in Long,P. Bliss,E. Clinical & Experimental Use of Sulfanilamide... Macmillan Co. 1939. 8. Levaditi,C. Vaisman,A. 1935. cited in Long,P. Bliss,E. ibid. 9. Nitti,F. Bovet,D. 1935. cited in Long,P. Bliss,E. op cit. 10. Long,P. Bliss,E. Clinical & Experimental Use of Sulfanilamide... Macmillan 11. Domagk,G. 1937. cited in ibid. 12. Long,P. Bliss,E. Clinical & Experimental Use of Sulfanilamide... Macmillan 13. Sneader,W. Drug Discovery. John Wiley & Sons. 1985. 14. Macfarlane,G. Howard Florey... 15. Howie,J. BMJ. vol 293. 1986. 16. Macfarlane,G. Howard Florey... 17. Macfarlane,G. Alexander Fleming: the man and the myth. Hogarth Press. 1984 18. Florey,H. 1942. cited in ibid. 19. BBC Radio 4. Discovery of Penicillin. broadcast date - 20. Florey,H. Conquest. vol XLI. No 133. 1953. 21. Botting,J. RDS Newsletter. 1991. 22. Fisher,RB. 23. British National Formulary. Number 4. 1982. |
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