PREFERRED ANTISEPTICS
ANTISEPTIC SOLUTIONS
These are solutions used for the destruction of and to arrest the
progress of microörganisms that have found their way into wounds—the
cause of sepsis, as exhibited by fever, suppuration, and putrefaction.
These preparations are called antiseptics and are used to render parts
aseptic. They vary much in their destructive power, effect on tissue, and
toxic properties. The reader is referred to a work on bacteriology for
the specific knowledge of such on germ life.
The antiseptic treatment of wounds was founded by Joseph Lister, 1865-70,
then called Listerism. His one chemical agent to accomplish this was
carbolic acid, but many such and more effective agents have been added
since that time, all differing in their specific properties and each
having, for the same reason, its particular use.
The following group of antiseptics has been chosen with a view of giving
the best selection, to which the author has added a short description of
each, so that the surgeon may choose one or the other, as the occasion
may demand. As a rule, an operator cultivates the use of a certain line
of antisepsis, especially in this branch of surgery, experience being the
best guide; yet it is hoped he may find certain aid from those referred
to, their particular use being pointed out from time to time, as the
author has had occasion to prefer one or the other.
=Alcohol= (_absolute_).—This is a well-known antiseptic, but, because of
its ready evaporation, is especially used for the hands, as described,
and to cover sharp-edged instruments after sterilization.
=Aluminum Acetate= (_Bürow_, _H. Maas_).—A powerful, nontoxic antiseptic.
Is used only in two- to five-per-cent solution. According to Primer,
it arrests the development of schizomycetes, and in twenty-four hours
destroys their propagation. It readily removes offensive odors of wounds;
its great objections are that it injures the instruments, and, because
of its astringent nature, roughens the skin of the hands. This, however,
makes it particularly useful for sponging to arrest capillary oozing.
=Boric Acid= (_Lister_).—Not a powerful, but nonirritating, antiseptic.
For this reason it is used extensively in cleansing mucous membranes,
and, when associated with salicylic acid, as in the well-known Thiersch
solutions, composed of salicylic acid, 2 gms.; boric acid, 12 gms.;
water, 1,000 gms., is much used in skin-grafting operations. It is
not very soluble in cold, but readily in hot, water and alcohol. The
saturated solution is prepared by adding ℥j to the pint of boiling water.
=Benzoic Acid.=—Nonirritating, moderate antiseptic (Kraske); is prepared
in 1-250 solutions. Soluble in hot water and alcohol, but sparingly in
cold water.
=Carbolic Acid= (_Phenylic Acid_).—Not a powerful, but a much-used
antiseptic. The purest acid should be used. It appears as a colorless
crystalline solid, liquefied by the addition of five per cent water. If
more water is added the solution becomes turbid, clearing when 1-2,000 is
reached.
It is readily soluble in glycerin, alcohol, ether, and the fixed volatile
oils. Solutions in alcohol and oils have no antiseptic effect (Koch). The
1-20 aqueous solution is recommended by Lister.
The aqueous solutions used in surgery are 1-20 and 1-40. The weaker
is used for the operator’s hands, to cover instruments, as already
mentioned, and to impregnate sponges. The stronger solution is used
for the carbolic spray, to cleanse the unbroken skin about the site of
operation, and to disinfect wounds. Either solution, when applied to an
open wound, whitens the raw surface, coagulates the albumen, and causes
considerable irritation, which subsides quickly and is followed by
numbness.
Such solutions, by virtue of their irritant nature, increase the serous
discharge from a wound for about twenty-four hours, for which proper
drainage must be provided, as by its collection it would add to the
danger by increasing inflammation and suppuration, and, by absorption,
even produce toxic effect generally.
When a cold solution is used it should be prepared by vigorous stirring
to separate the globules of the acid. Hot water insures perfect
distribution. After an infected wound is washed with it, the solution
should not again be used, nor should any of the acid be permitted to
remain in the spaces about the wound. It will be found that many patients
cannot tolerate such dressings, and that others must be substituted.
Large surfaces should never be exposed to carbolic solutions, because
the skin absorbs them readily, followed by untoward results. Dangerous
symptoms have been known to result from the internal administration of
seven drops of the acid, and fatal termination has followed its use as a
surgical dressing (Bartley).
Mild acid poisoning is first noted in the urine, which turns olive green.
If the agent is continued, the urine appears dark and turns almost black
on standing. The coloring is due to the presence of indican. If the
absorption is not prevented beyond this there is dull frontal aching,
tinnitus aurium, dizziness, fainting, severe and uncontrollable vomiting.
Untoward symptoms are noted by albuminuria, total absence of sulphates in
the urine, a contracted and inactive pupil, elevation of temperature,
unconsciousness, muscular contraction, and death.
The treatment consists in immediately removing the cause and employing
another antiseptic. Support the patient with stimulants, freely given.
Cracked ice and brandy to allay the vomiting. Small doses of sodium
sulphate, frequently repeated, as a means of converting the acid into
nonpoisonous sulphocarbolate (Bauman). Albumen and milk internally.
Magnesium sulphate, five per cent.
=Chromic Anhydrid.=—Improperly called chromic acid. Made by adding one
and one half parts sulphuric acid, c. p., to one part of concentrated
solution of dichromate of potash. Appears in saffron-colored crystals.
It acts as a caustic upon tissue, and, although a splendid antiseptic,
cannot be used for such purposes, but is well adapted for the preparation
of catgut, as mentioned.
=Creolin.=—Is an antiseptic prepared from coal by dry distillation, and
is used to stimulate granulations, being much more powerful than carbolic
acid. It is nonirritant and practically nontoxic. Used in two-per-cent
aqueous solutions, in which it appears as a turbid but effective mixture.
It is well suited for cleansing the hands, a five-per-cent solution
having none of the irritating or anesthetic effect of carbolic acid.
Owing to the opacity of the aqueous solution, it is not suitable for the
immersion of instruments for operation.
=Eucalyptol= (_W. Schultz_).—A nonpoisonous volatile oil of considerable
antiseptic power. Soluble in alcohol, and used in three-per-cent
solution. It is claimed to quickly reduce the temperature in a wound. It
was much used by Lister on gauze dressings, the formula of which is given
elsewhere.
=Glycerin.=—It is said to have certain antiseptic power, but is used
principally as a staple solvent of carbolic and boric acid. Soluble in
all proportions in water and alcohol.
=Hydrargyrum Bichloratum Corrosivum= (_v. Bergman_, _Schede_, _Buchholz_,
_Billroth_, _R. Koch_).—The most valuable and effective, although the
most toxic of all antiseptics. It appears as a white crystalline powder.
A 1-50,000 watery solution is efficacious as a germicide (Koch; anthrax
bacilli killed by 1-20,000 solution). Albumen decomposes the bichlorid,
forming a white insoluble precipitate, albuminate of mercury. The same
effect takes place in aqueous solutions allowed to stand for a time—the
resultant being either calomel or metallic mercury. The addition of
sodium or ammonium chlorid or a weak acid, such as tartaric, prevents
this. As much sodium as of the sublimate, weight for weight, should be
used (Koch). When tartaric acid is used for this purpose, five times the
weight of the sublimate is employed.
For all surgical purposes, except in irrigation, solutions of 1-500 and
1-1,000 are used. For the sterilization of wounds and during operations a
1-3,000 is employed.
For the ready preparation of such solutions sublimate tablets can be
obtained, properly mixed with one of the above-named salts. The dyed
tablets are to be preferred, to prevent error on the part of the user.
Tablets containing 1 gm. sublimate, 1 gm. sodium chlorid, and colored
with eosin, are advocated by Angerer.
As metallic substances immediately decompose the bichlorid in solution,
instruments cannot be placed in it, nor may it be kept in metallic
vessels, glass being preferred.
Alcoholic solutions of sublimate are used to cover catgut, silk, and
rubber drainage tubes.
Since sublimate is extremely toxic, great care must be used to prevent
its absorption or retention in wounds. A strong solution must immediately
be followed by a weaker one.
Toxic symptoms resemble arsenic poisoning very much, and are ushered in
by an acute irritation of the wound, especially if moist sublimated gauze
has been used, vertigo, and vomiting. The mucous membrane of the mouth
becomes affected, followed by salivation and bleeding from the gums.
There may be intestinal hemorrhage and an inflammation of the entire
intestinal tract and kidneys, increasing in severity and resulting in
death.
The early symptoms must be at once met by removal of the cause. Albumen
and milk should be given internally, with stimulants as needed. The mouth
is to be rinsed out at frequent intervals with a saturated solution of
chlorate of potash.
=Hydrogen Peroxid= (_Love_).—A powerful nontoxic antiseptic. It is used
in five- to fifty-per-cent aqueous solutions, and is most efficacious in
suppurating wounds, in which it destroys the microörganisms of pus. It
foams actively when brought in contact with the latter, and is said to
render a wound aseptic by one or two applications. A standard preparation
of known strength must be obtained, however, to get good results.
=Iodin.=—A very powerful nonirritating antiseptic. Used especially for
washing wounds. The proper solution is made by mixing two drams of the
tincture (℥j iodin to ℥Oj alcohol) with one pint of warm water (Bryant).
The one-per-cent solution of the trichlorid is equal in its effectiveness
to a four-per-cent carbolic solution (Langenbuch).
=Lysol.=—Very similar to creolin, both in composition and effect. Is
nontoxic, and employed in two-per-cent aqueous solution. Appears as a
soapy liquid, and forms a clear solution with water.
=Potassium Permanganate.=—An active disinfectant, quickly destroying the
odor of decomposition, and for that reason is splendid for the washing
out of foul wounds. It is nonpoisonous, and has moderate antiseptic
power—the five-per-cent solution killing resting spores. Its effect is
limited to a short time only, as the secretions from a wound decompose
and precipitate it into an inactive form. It is employed in aqueous
solution, differing in color from light ruby to dark brown; that is,
1-1,000 to 1-100. The solution, known as Condy’s Fluid, has a strength of
1-1,000.
=Salicylic Acid.=—A derivative of carbolic acid, and an effective
nonirritating antiseptic. It is only slightly soluble in cold water,
1-300. When combined with boric acid, it becomes more soluble. This
antiseptic cannot be used for instruments, however, as it corrodes them.
Its other objections are that it evaporates quickly from dressings and
that it is expensive.
=Sodium Chlorid.=—Is a common agent used for the irrigation of putrid
wounds in two-per-cent solution. For irrigation during aseptic operation
and for covering sterilized sponges it is used in eight-per-cent solution
(v. Esmarch). This corresponding to the normal salt solution. Its use in
connection with corrosive-sublimate solutions (Maas) has been referred to.
=Thymol= (_Rancke_, _Bouillon_, _Paquel_).—The aromatic principle of
thyme. Efficient as an antiseptic in 1-1,000 aqueous solution. It has a
pleasant odor, and is nonirritant and nontoxic. Exhibited in colorless
crystals. An excellent solution is prepared as follows:
℞ Thymol 20 parts
Alcohol 10 ”
Glycerin 20 ”
Aquæ 1,000 ”
It is used especially in washing out cavities where carbolic acid cannot
be employed, and for cleansing mucous membranes preparatory to operation.
=Zinc Chlorid= (_Morgan_, _Bardeleben_, _Billroth_).—Extensively used
as an antiseptic, especially in the oral cavity, where, by sealing the
lymph spaces with a plastic exudate, it hinders the absorption of septic
matter. It is only slightly antiseptic, however, in ten-per-cent aqueous
solution. Zinc chlorid represents the active agent in Burnett’s fluid.
May be effectively employed in the proportions of from twenty to forty
grains to the ounce of water. Care must be exercised to prevent its
retention in alveolar tissue, since it may occasion serious sloughing. As
a cleansing agent for infected wounds it is of great value, although the
sulphocarbolate of zinc may be preferred, as it is less irritating and
less toxic.
=Peroxoles.=—Beck has introduced a group of preparations, known as
peroxoles; liquid antiseptics containing a solution of hydrogen peroxid
in combination with other disinfectants. The preparations are composed of
from thirty-three to thirty-eight per cent alcohol, about three per cent
of hydrogen peroxid, and one per cent of thymol, menthol, or camphor,
the name given them being according to the last ingredient—thymosol,
menthosol, or camphorosol. The association with these disinfectants
greatly increases the antiseptic power of hydrogen peroxid. Aqueous
solutions containing ten per cent of the peroxoles are usually employed.
These correspond to a one-per-cent solution of mercuric chlorid, and
possess a more energetic action than five per cent carbolic acid.
ANTISEPTIC POWDERS
=Aristol= (_Dithymol Di-iodid_) (_Eichhoff_).—Reddish-brown powder
containing forty per cent iodin. Soluble in ether, chloroform, and fatty
oils, sparingly in alcohol. Must be kept in dark glass bottles. Is
incompatible with corrosive solutions. Used externally as iodoform.
=Dermatol= (_Bismuth Subgallate_).—An odorless yellow insoluble powder,
containing fifty-three per cent Bi₂O₃.
=Iodol= (_Tetraido Pyrol_) (_Kalle_).—A light grayish-brown powder,
containing eighty-nine per cent iodid. Slightly soluble in water, soluble
in alcohol and chloroform. Its action is very similar to iodoform, and
has taken its place to a great extent, first, because it is odorless, and
secondly, because any quantity used exerts no toxic effect (Wolfenden).
It is dusted upon the wound. Its action is due to the liberation of
iodin, which acts upon the albuminous elements, and the ozone set free
oxidizes the products of decomposition. It has a slight escharotic
effect, forming a thin crust over the surface to which it is applied,
thus effectually remaining in constant contact with it. That it is
quickly absorbed is shown by its presence in the saliva and the urine.
=Orthoform= (_Methyl Ester of Meta-Amido-Para-Oxybenzoic
Acid_).—Nonpoisonous, white, odorless powder of moderate antiseptic
power, and well suited for wounds involving mucous membranes. It has a
decided anesthetic effect, lasting for several hours upon painful wound
surfaces.
=Iodoform= (_Formyl Iodid_, _Féréol_).—A lemon-yellow crystalline powder
of penetrating, saffronlike odor. Contains ninety-seven per cent iodin.
Insoluble in water, but forms solution with alcohol, ether, chloroform,
and the fixed volatile oils. Has a decided stimulating effect on wounds
by preventing putrefaction and deodorization (Mikulicz). Its antiseptic
value has been much discussed, but practically it has found favor with
the majority of surgeons. According to research, iodoform is a powerful
antiseptic, from the fact that the product of its decomposition in
the presence of germ life renders the ptomains in a wound inert, thus
preventing suppuration, or at least checking the absorption of such,
which is often a serious matter in infected wounds. It is not sterile,
and may contain ptomains which in themselves would produce pus, but as
associated with the iodoform do not occasion it.