THE HISTORY OF ANTISEPSIS.
_Sepsis, Asepsis, and Antisepsis. The Germ-theory of Disease.
Gay-Lussac's Researches. Schwann. Tyndall. Pasteur. Davaine. Lord Lister
and his Epoch-making Revolution in Surgical Methods. Modifications of
his Earlier Technique without Change in Underlying Principles, which
Still Remain Unshaken. Changes Effected in Consequence. Comparison of
Old and Modern Statistics._
Modern{316} surgery, and, in no small degree, modern treatment of all
disease, have been so completely modified from previous methods by the
introduction of the so-called antiseptic system that it seems to be only
right to devote some time in such a work as this to a _résumé_ of
the history of the doctrines and experiments which have led to the
perfection, as it would seem, of modern methods.
The adjective "septic" comes from the Greek word "sepsis," which is
often transferred to the English, and which means "putrefaction," or
that which is putrid, or undergoing decomposition. From this word
are formed two others,--namely, "aseptic" and "antiseptic,"--the one
implying the exclusion of all causes of putrefaction and complete
freedom from it, the other referring to methods employed to antidote the
effect or counteract the influence of the agencies which produce sepsis
or destroy them while still within the living body. By general usage the
term "antiseptic" has been construed as the more comprehensive; hence,
the modern method is usually spoken of as "antiseptic surgery," and
hence the title above: "The History of Antisepsis."
The principle underlying the resort to antiseptic methods is summed
up in the expression, now so generally received,--the "germ-theory" of
disease. It refers, in general, to the so-called zymotic, or infectious,
diseases, whose manifestations are protean, which are all communicable
by one means{317} or another, but which are not all necessarily
contagious; some of which, being not at all amenable to surgical
treatment, are regarded as "medical" diseases, while others, which occur
mostly in connection with surgical cases, or which lead to conditions
requiring surgical relief, are usually spoken of as "surgical" diseases.
As excellent and only too common examples of these zymotic diseases may
be mentioned tetanus, erysipelas, puerperal fever, typhoid fever, and
those varied conditions which are generally grouped under the term
"blood poisoning." Those which most concern the surgeon, and those in
which most remarkable relief has been obtained are erysipelas and the
various forms of blood poisoning. These, in their varied manifestations,
have, until recently, been literally the terror of surgeons, and in
military hospitals, for instance, have been the cause of more deaths
than have ever resulted from wounds directly upon the battle-field.
In civil hospitals, as well as in general and private practice, the
mortality from these diseases was, until twenty-five years ago, simply
frightful; while frequently, and over wide areas of territory, endemics
and epidemics of puerperal fever would result in the death of almost
every lying-in woman. In consequence of this terrible death-rate
surgeons were afraid to operate, and certain classes of operations,
especially those on the abdomen and joints, were never performed, except
under most exacting circumstances. But few of the present generation can
actually realize the completeness of the changes brought about by the
adoption of the germ-theory, and the practical effect of its use as a
working basis for combating disease.
While no intelligent student at present denies that the infectious
diseases--of which the above named are but a very few--are the result
of the introduction into the body, from without, of minute living
organisms, for the most part vegetable,--thus constituting them in
reality, as they are often called, _parasitic_ diseases,--but few are so
familiar with{318} the history of modern discovery as to appreciate the
basis upon which it has been demonstrated. The proof of the germ origin
of disease is the legitimate outcome of the discovery of the actual
causes of fermentation and putrefaction.
Aside from the crude and often wild notions which have appeared here
and there in literature of previous centuries, about the first accurate
investigations bearing upon this subject were with reference to the
cause of alcoholic fermentation. About the beginning of this century
Appert published a monograph upon the Art of Preserving Animal and
Vegetable Substances, which consisted in placing them in closely corked
or stoppered bottles, and exposing these to the temperature of boiling
water. Gay-Lussac, the celebrated chemist, noticed that so soon as these
vessels were opened, particularly if much exposed to air, their contents
began to at once ferment or putrefy. This led to investigations into
the production of alcohol, and the antiseptic effect of pure oxygen-gas;
from which he concluded that oxvgen is necessary at the commencement
of the process, but not throughout its continuance. Some thirty years
later, Schwann, by the use of the microscope, then reasonably developed,
discovered in fermenting substances numerous very minute globular
bodies, which had the power of reproduction, and which were present in
juices or fluids undergoing alcoholic fermentation, but not in others,
and which he concluded to be the exciting cause. Schwann also discovered
that if, in vessels sealed by Appert's method, lie allowed air which
had been previously heated to come in contact with the fluids, no change
resulted; from which it was evident that it was something other than
the gaseous elements of the air which provoked fermentation. Schwann's
investigations were corroborated, in 1843, by Helmholtz.
Schwann's results were contested by Liebig, one of the most eminent
chemists of his time, who proposed a very different{319} theory,
ascribing putrefaction to the absence of oxygen and to the upsetting of
molecular arrangements. He believed that non-nitrogenous substances
did not spontaneously undergo putrefaction when pure, but they must
be brought into contact with some substance already undergoing change,
which latter was called a _ferment_, and which converted the oxygen
of the air into carbonic acid. According to him, the ferment was some
material undergoing decomposition.
The next researches on this subject were those of Schroeder and Dusch,
in 1854 who studied the question whether filtration of air would prevent
the fermentation of boiled fluids to which such filtered air might
have access. The material used for filtration was cotton-wool; and they
showed that air filtered through it was deprived of the agencies which
produce fermentation. Then came Pasteur, who repeated the experiments of
his predecessors and elaborated and confirmed them. He also found that
it was not necessary to filter the air of its contained particles,
but that if it were simply left undisturbed until these had settled by
gravity, it might then be brought in contact with putrescible substances
without causing any putrefaction.
In 1870, in a lecture upon haze and dust, Tyndall demonstrated
beautifully and in public the presence of countless particles in the
air, as well as that these were the agencies operating to produce
undesirable changes in organic substances. Both Pasteur and Tyndall,
as well as others, showed, as did also Lister, that heat as well as
filtration was sufficient to render these particles innocuous. As the
result of these and numerous other experiments, by various observers,
which there is no time here to recount, it was gradually and irrefutably
established that the gases of the air, _per se_, are powerless to cause
fermentation or putrefaction in boiled fluids or tissues, or in material
germ-free when exposed. It was sufficient, in order to so purify{320}
the air, to either previously heat it or filter it through cotton-wool
or through fluids inimical to germ-life, while the boiling of
organic material or its subjection to the boiling heat of water was
sufficient to destroy all germ-activity in it at the time, or, as we
say now, to sterilize it.
In this way, and even before any minute and systematic study of
bacteria,--i.e., before the inauguration of bacteriology as a separate
department of scientific study,--it was practically established that the
agencies which produce putrefactive changes or fermentation were minute
particles which were ever present in almost every substance, and that by
heat or something corresponding to filtration it was possible to remove
them or destroy their activity.
So much had been established without reference to the etiology of
disease. In order now to study the germ-theory of disease as applied
to man we must go back a little, neglecting the vagaries or the
pure conjectures of the ancients, to the era of pure philosophic
speculation,--perhaps to the days of Needham and Buffon.--to the middle
of the previous century, when scientists and naturalists began to
discuss the so-called spontaneous generation of life; for it is well
known that fluids, like milk and others, abound with life after a few
days of exposure; and it was supposed that the living organisms it
contained had a spontaneous origin. This question of the spontaneous
beginning of minute living forms was agitated for a century, or
practically until Tyndall and Pasteur gave it its death-blow by
their accurate and convincing demonstrations. There was no lark of
experimentation, but there was lack of exact knowledge and of accurate
deduction from facts observed. The bacteria--which at that time
were usually spoken of as "monads" and "vibriones," because of their
spontaneous motion--were found under varying circumstances, which,
not being scientifically inquired into, led thinking men into a most
perplexing condition{321} of mind. The two most ardent recent advocates
of spontaneous generation were Bastian, of England, who wrote an
elaborate treatise upon the subject, and Jeffries Wyman, of Cambridge,
Mass., who gave it the benefit of all his influence. But, under the
influence of blows dealt from the side of the physical laboratory by
Tyndall, and from that of the biologists by Pasteur, the theory was
weakened and effectually killed, so that to-day no one thinks of such
a thing. On the contrary, life seems to be inevitably the gift of a
preceding organism; and while the real origin of life is as unknown
to-day as ever, there is not a single fact in the possession of
scientists now justifying the view that life can have a spontaneous
origin. Moreover the researches of Pasteur and others into alcoholic
fermentation and the rôle played by the minute yeast-plant, and
the early researches of Pasteur, Davaine, and Koch into the rôle of
micro-organisms in producing disease in animals, and the scientific and
elaborate study of bacteria and vegetable molds, inaugurated by Cohn and
continued by many others, have as their legitimate outcome the creation
of bacteriology as a science, and the establishment of the fact that
the real condition in the so-called infectious diseases is one of
fermentative or putrefactive alterations in the fluids and tissues of
the living body, corresponding in minutiæ to the changes produced
in saccharine fluids by the yeast-plant, or in decomposing animal
or vegetable matter by the many known bacteria which are capable of
producing such changes. To put it in another way, disease is simply an
expression of the fact that these minute organisms, which are visible
only under high powers of the microscope and which reproduce their kind
with astonishing rapidity, gaining access to the surface or interior of
the body, begin there to thrive and multiply, taking up from the living
animal material for their own nourishment, thus robbing their host of
that upon which his tissues must live, while at the same time, as the
result of their activity, they produce{322} various substances which,
so far as they are concerned, are excretory in nature, and many of which
are extremely poisonous to the animal organism which harbors them. Such
a disease as puerperal fever, for instance, is simply an expression
of the fact that within the living human body there is going on active
putrefactive action by which the internal cells are being destroyed.
this destruction being progressive and often far-reaching; and that, as
the result of their presence in the still living body, the noxious
or toxic excretory materials of which they get rid are absorbed, in
consequence of which such varying symptoms as nausea, fever, purging,
vomiting, delirium, and many other symptoms are produced, the objective
evidence of their local activity being the actual destruction of
tissues, as is seen in cases of abscess, phlegmonous erysipelas, etc.
The condition known everywhere as gangrene, when moist and offensive,
is nothing but the putrefaction of tissues _en masse_ which are not yet
detached or separated from the living body of which they but recently
formed a living part.
Experiments with organic material outside the body have amply
demonstrated that such putrefactive processes can be checked by certain
precautions--such as filtration of air, heat, etc. It remained for
the genius of Lister to show how similar processes of putrefaction
and exclusion of germs could be made serviceable for the prevention of
disease in the human race. To Lister, then, is due the credit of having
originated the antiseptic system and brought about a condition long
yearned for by surgeons throughout the world, but never previously
attained. What a revolution he wrought by his masterly researches can be
appreciated only when one compares the impunity with which surgeons now
perform operations which, in the previous era were regarded as
absolutley unjustifiable--a conclusion amply warranted by the statistics
of that era.
Great as the credit due to Lister, it is equally desirable to state
that his work was, for the most part, based upon Lister's, the{323}
researches of Tyndall, Pasteur, and Koch, which had established the germ
nature of the terrible infectious diseases and the germicidal effect of
filtration, of heat, and of certain other substances and methods which
permitted of the development of his own system.
[Illustration: 0343]
The antiseptic method, as it has since been known, was naturally at
first crude, although its scientific basis has never been shaken; and
that it has been since, in large measure, modified, and that surgeons
now resort to little, if any, of the paraphernalia which first made it
such a formal proceeding, in no regard shake the scientific nature
of its foundation, but rather have tended ever to corroborate it and
establish it more and more firmly. Lister began with the supposition
that the air contains the germs which are most active and pernicious
in producing disease. It has been since learned that air-contact is,
perhaps, least of all to{324} be dreaded. We, however, recognize the
germs as always the efficient agents, though we have since learned that
other sources of contamination are much more to be dreaded than air.
It had been the custom, up to Lister's time, to observe usually the
ordinary forms of cleanliness, but, not appreciating the multitude of
germs which lurk in and about the skin, it had not been customary to
scour and prepare it as we have learned to do since Lister's day. The
ligatures and instruments which were used and the dressings which were
applied, as well as the sponges used during the operation, usually went
through the ordinary forms of cleansing; and yet Lister's investigations
showed the utter inadequacy of such preparation. His most important
object-lesson, however, was that everything that came in contact with
fresh or bleeding tissues might carry infectious material (i.e.,
germs), unless it had itself been thoroughly freed from their
presence. Accordingly, the system taught the accurate preparation of
everything.--from the skin of the patient, which was to be carefully
cleansed and shaven, to the hands of the operator, which were to be
scrupulously scrubbed, as well as those of every assistant who might
handle or touch any of the instruments or dressing materials. It
included, also, the careful preparation of sponges, sutures, and
ligature materials, all of which were kept protected from air-contact
and in antiseptic solutions until the moment of their use. The dressing
materials were impregnated with substances like carbolic acid, which had
been proven to be germicidal; and impermeable material, like oiled silk,
was used to cover the surgical dressing, in order that fluids which
might leak through should not come in contact with the air, which might
permit of their putrefaction, while, at the same time, air from without
could have no access to the deeper parts thus protected.
The original method of Lister was very elaborate, and included also the
dissemination throughout the air of the operating-room{325} of a vapor
of carbolic acid, which was disagreeable, sometimes almost fatal, to
operators and bystanders alike,--its use being based upon the notion
that the air was the substance most to be dreaded. The instruments were
placed in strong antiseptic solutions, usually carbolic, which were
pungent and irritating to the hands of all that came in contact with
them. So thoroughly and ubiquitously were antiseptic materials employed
that it was soon learned that they were of themselves rather injurious
to the best interests of the patients upon whom they were employed.
Their use, of course, was contingent upon the notion, then everywhere
prevalent, that powerful substances must be used in order to counteract
the activity of the much-dreaded germs.
In the course of time, however, it was learned that the air was not so
much to be dreaded as had been supposed, and that even if it came in
contact with raw tissues infection did not certainly follow. It was
found also that the antiseptic solutions which had been so freely used
for irrigating or drenching the parts during an operation were by no
means essential, and that tissues often healed better which had not been
subjected to so much irritation. It was learned further that it was not
necessary to impregnate dressings with these same solutions, providing,
in the first place, they were carefully sterilized by the application
of heat, which in time came to be used for the purpose of sterilizing
everything not injuriously affected by it. In consequence, then, all
dressing material, silk ligatures, instruments, nail-brushes, etc., were
subjected to live steam or to boiling water for twenty minutes or more,
which was demonstrated to be completely effective in the destruction
of all organic or bacterial life. This, of itself, was a very great
simplification of the antiseptic method. It was also demonstrated that
the vital fluids of the animal body had of themselves great germicidal
power, and that the strong antiseptic fluids previously used tended
rather to impair{326} this power than to enhance it. Accordingly, fluids
for irrigation came to be used only when there was some noxious material
to be washed away. It was found that fresh wounds healed most kindly
when least irritated by applications of any kind, providing only that
nothing came in contact with them which could infect them. And, in this
way, as well as by resort to simpler rather than complicated procedures,
there was gradually substituted for the so-called _anti_septic method
that which is now everywhere recognized, and always practiced, when
possible,--i.e., the aseptic method. This simply means that it is very
much better to exclude germs than to permit of their access and then try
to kill them after they have lodged. The aseptic method is, therefore,
now in vogue, and among the best operators always the so-called _dry_
method of operating, which means that, so far as possible, nothing not
absolutely needed at the moment should come in contact with the field
of operation. This has been, in many respects, a great advance over
the older antiseptic method, though based upon absolutely the same
recognition of causes, being only an improvement in technique.
The benefits of Lister's studies, and of that which has grown out of
them, are simply incalculable. The surgical infections which, thirty
years ago, were the dread of all operating surgeons, have practically
disappeared from civil and military hospitals. I esteem myself fortunate
in this,--that I have been a living witness of the benefit of change
from the old to the new, since when I began my work, in 1876 (over
twenty years ago), as a hospital _interne_, in one of the largest
hospitals in this country, it happened that during my first winter's
experience,--with but one or two exceptions,--every patient operated
upon in that hospital, and that by men who were esteemed the peers of
any one in their day, died of blood poisoning, while I myself nearly
perished from the same disease. This was in an absolutely new building,
where expenditure had been lavish; one whose{327} walls were not reeking
with germs, as is the case yet in many of the old and well-established
institutions. With the introduction of the antiseptic method, during the
two years following, this frightful mortality was reduced to the average
of the day, and in the same institution to-day is done as good work as
that seen anywhere. The same was true without exception in the great
hospitals of the Old World; and in Paris, where, thirty years ago,
famous surgeons would go from one end of the building to the other,
handling one patient after another without ever washing their hands,
and where erysipelas and contagion of various kinds were thoroughly
distributed, as it were, impartially, now the successors of these
very same men, employing modern methods, get results which challenge
comparison.
The world has seen few extensive wars since the introduction of the
antiseptic system; but, in such as have occurred, its incalculable value
in military hospitals has been amply demonstrated. The modern soldier is
now taught how to make a prompt occlusive and antiseptic dressing of the
wound which he may receive upon the battle-field, which, from the
moment of its attention, continues to be treated according to the same
enlightened method after he reaches the field-hospital, or when sent to
the rear; so that men now receive extensive injuries to joints and to
viscera, which previously were either promptly fatal, or fatal within a
few days from erysipelas and hospital gangrene, from which they recover
with useful--often with nearly perfect--limb or function of part
restored.
The military hospital of to-day is, therefore, robbed of the terrors
which used to make it almost a charnel-house; hospital gangrene,
the special dread of active army-surgeons in time past, has almost
disappeared from the category of known diseases, and one of the greatest
dangers menacing the modern soldier has been removed from modern
civilized life. The method has met with universal adoption among
all{328} civilized races and peoples, and all this through the energy
and talent of the originator, now Sir Joseph Lister.
With the recognition of the germ nature of so many acute diseases has
come also systematic study of the use of antiseptics internally; and,
while no such exceeding satisfaction has resulted from labors in this
direction, we have, nevertheless, learned that most of the infectious
diseases of the alimentary canal--for example, cholera, typhoid,
etc.--are well attacked by means of antiseptics administered internally;
that many of the conditions that depress and annoy are due to the
presence of germs in the alimentary canal and the urinary system, and
are best combated by means which shall remove these agencies, if not
destroy them. It has been learned, also, that many forms of skin disease
are parasitic, and that these are only successfully treated by the
employment of antiseptics externally.
And so the recognition of the germ nature of infectious diseases and
the germicidal properties of certain substances, now spoken of as
antiseptics, have kept pace, the one with the other; and in consequence
the world has reached a period in its medical history never even dreamed
of by our forefathers, when the infectious diseases have been shown
to be practically preventable and, to a large extent, curable by the
employment of drugs directed especially against their exciting cause.
What the years to come may have in the way of further discovery in this
direction, we may not foresee. So far as one can at present see ahead,
the next advances must be in the direction either of means which
shall fortify the human organism against the inroads of bacteria, or
disease-germs, or else in the discovery of substances, such as we do
not yet know, which shall be at the same time poisonous to the germs
and innocuous to the patient, to whom they may be administered in doses
sufficient for their purpose. Any material possessing these properties
would be an ideal antiseptic for internal purposes. At present we only
approach our ideal, but are very{329} far from its active realization.
In no way would mankind be more greatly benefited than by the
prosecution of studies which may lead to satisfactory results in either
of these directions.