+ASEPSIS AND ANTISEPSIS+
Before the introduction of Lister’s methods of treating wounds, it was
considered proper, in accidental and operative wounds, to have profuse
suppuration, pyemia, erysipelas, etc., and it was not remarkable,
therefore, that the mortality following accidental and operative
wounds was very high. Lister’s method of wound treatment was largely
based upon the conception that the infection of wounds occurred from
contact with the air which contained spores and germs, and his method
of treatment therefore, was directed chiefly to their destruction. The
air can be a medium of wound infection to a certain extent, and dry
air contains more spores and bacteria than moist air, but Koch
demonstrated the fact that atmospheric microbes were chiefly of
innocuous character, and wound infection usually could be traced to
bacteria or spores being brought into direct contact with wounds, by
the clothing, or by the skin of the patient, or by the hands of the
surgeon, or by unclean surgical instruments and dressings. The
antiseptic qualities of the blood serum and cell activities in healthy
tissues, are sufficient to destroy or remove a certain number of
microorganisms, and suppuration occurs only when the tissues are
completely overwhelmed by the number of these organisms or when their
power of resistance is lessened by injury or disease.
+Sepsis.+ Sepsis is due to the entrance and multiplication of microbes,
or to the absorption of their products in the body. Local
inflammation and marked constitutional symptoms characterize sepsis.
+Asepsis.+ Asepsis aims at thorough sterilization of the parts and of
all the objects brought into contact with the wounds, and the
exclusion of germs by the use of occlusive bandages and dressings.
+Antisepsis+ is that method of wound treatment which keeps germicidal
agents continuously in direct contact with the wound. Its object,
therefore, is to produce asepsis. It is the duty of the surgeon to
guard against the contact of microorganisms in the wound and to employ
whatever means science has evolved for their destruction. He must,
however, be careful to employ means of disinfection or destruction
that will not have an injurious effect upon the normal tissues.
Mechanical disinfection does not apply to wounds but is employed as a
preventive measure by the operator and his assistants for instruments
and for the skin surrounding the wounds. Mechanical disinfection is
accomplished by the use of soap and water and a friction brush;
germicidal solutions of one kind or another are also employed.
In the modern aseptic operating room germicides and antiseptics do not
play so important a part as they formerly did. This is largely due to
the fact that heat is used wherever possible in the preparation of
sutures, ligatures, dressings and instruments, and to the farther fact
that in uninfected tissues no antiseptic solutions are employed. It
must also be remembered that the germicidal agents possess the
disadvantage of exercising a more or less destructive action on the
body cells, and consequently their use is not warranted in clean
wounds. We still, however, sufficiently often meet with infected
wounds that render the use of these agents necessary.
+Heat+ is the most valuable of all sterilizing agents, its only drawback
being that it is not universally applicable. Wherever possible it
should be employed in preference to chemical agents. It can be
employed either dry or moist. Moist heat is a much more efficacious
germicide than dry heat, for it destroys the organisms at a much
lower temperature. Boiling water at a temperature of 212°F. will
destroy nearly instantaneously all pus-producing organisms. Spores,
however, require a moist heat of 284°F. kept up for at least a
half-hour. A dry heat of 212°F. will not destroy pus-producing
organisms under an hour and a half of treatment, and spores will live
for three hours at a dry temperature of 284°F.
Although moist heat is very much quicker and more satisfactory in its
action, yet it is often inconvenient to employ it in the sterilization
of gowns, towels, operating suits, etc. However, sterilization by heat
has been greatly facilitated by the introduction of the autoclave, by
means of which a very high temperature under pressure can be obtained.
This is the most satisfactory method of sterilizing dressings, towels,
sheets, operating suits and aprons. A similar and less expensive
method of sterilizing these articles is by the use of one of the
simple steam sterilizers which are sold by all dealers. In an
emergency, an ordinary bake oven can be employed as a sterilizer. It
is best, however, where the temperature cannot be estimated, to boil
the articles and dry them between sheets moistened with bichloride
solution.
+Disinfection or Sterilization.+ Sterilization of a wound, or of the
substances coming in contact with it, may be accomplished by using the
aseptic or antiseptic method; by combining these two methods we obtain
the best results. The aseptic method, which employs antiseptic
substances for the purpose of sterilization of objects coming in
contact with the wound when their disinfection by heat is impossible,
is the method perhaps most generally favored by modern surgeons.
+Antiseptic Method.+ In the antiseptic method, the field of operation,
the hands of the operator and of his assistants, and the instruments,
must be treated in germicidal solution and, in addition, the wound
should be frequently irrigated during the operation with a solution
that has germicidal properties.
Recent investigations show that many germicidal substances have not
the power that was formerly attributed to them. Furthermore,
substances which are really active germicides very often produce a
marked toxic effect upon the patient and produce a very decided
irritation of the skin with which they come in contact.
+Aseptic Methods.+ The aseptic method for the treatment of wounds admits
of the use of germicidal solutions and heat upon the field of
operation, upon the hands of the operator and of his assistants, and
upon the instruments employed. After this has been accomplished,
placing absolute dependence upon this sterilization, no germicidal or
antiseptic substances are brought into contact with the wound,
sterilized salt solution or plain sterilized water being used, if
necessary, to flush the wound, the dressings employed having been
sterilized by dry heat or moist heat.
+Sterilization of the Hands.+ Experimental investigation has shown that
the failure of the surgeon’s efforts to render his hands absolutely
aseptic, has been the productive cause of infection in many wounds.
The hands and finger nails may be best sterilized by first rubbing
them with spirits of turpentine; then scrubbing them with soap and
water; and then using a sterilized nail brush freely. The scrubbing
should be done for several minutes. The hands should then be rinsed to
remove the soap, and then soaked for about ten minutes in a solution
of bichloride, strength, 1 to 2500. If turpentine has not been used
before washing with the soap, strong alcohol or ether should be well
rubbed over the hands before they are immersed in the bichloride
solution. Perhaps the best way of rendering the hands sterile is to
scrub them with green soap and water, then mix a tablespoonful of
commercial chloride of lime and half a tablespoonful of carbonate of
soda with enough water to make a paste. When this has assumed a thick
creamy consistency, it should be rubbed into the hands until the
grains of lime disappear and the skin feels cool; then rinse the hands
in sterile water.
+Sterilization of Instruments.+ Instruments may be sterilized by
boiling them for fifteen minutes in water in which a tablespoonful of
washing soda has been added for each quart. This prevents rusting of
the instruments and also makes the water a better solvent for any
fatty matter which may be upon the instruments, thus increasing the
sterilizing effect of the heat.
+Sterilization of the Feet.+ As most patients do not apply water as
freely or as frequently to the feet as to other portions of the body,
there is usually present an excessive amount of thickened epidermis,
which is very difficult to render sterile. For operations in chiropody
the feet should be thoroughly moistened with soap and water, scrubbed
vigorously with a brush, then soaked in a solution of bichloride of
mercury of 1 to 1000 strength, and then wrapped up in a towel soaked
in the same solution while waiting for the operator.
+AGENTS EMPLOYED TO SECURE ASEPSIS+
+Bichloride of Mercury+ is used for the disinfection of the hands and
skin and for the irrigation of wounds. Biniodid of mercury is
extensively employed and in the same strengths as the bichloride. It
is, however, a more powerful germicide, while being less irritative,
and neither forms a mercuric albuminate nor tarnishes metal
instruments.
+Carbolic Acid.+ This acid is derived from coal tar, and although known
as early as 1834 as the first antiseptic recommended and used by
Lister, is not so popular since the discovery that bichloride of
mercury possesses more germicidal action.
Gangrene of the skin and subjacent tissues has often been traced to
the long continued use of dilute solutions of carbolic acid or of
ointments containing small quantities of the drug. Gangrene of the
fingers and toes is by no means infrequent as a consequence of its
use. Another condition frequently seen is the systemic poisoning
through absorption. One of the first symptoms noticed from such
absorption is irritation of the urinary tract and carboluria. This
poisoning is more apt to take place when the weaker solutions are used
than when the pure acid is used, as the destruction produced by the
pure acid prevents its absorption.
The effect of carbolic acid upon the urine (See Chapter II, “_Carbolic
Acid_”) is to cause it to become smoky a short time after it is
voided. The urine shows a complete absence or diminution of the
sulphates, and albumin is generally present. When these symptoms
present themselves, the use of carbolic acid should be withdrawn, and
the administration of sulphate of soda and atropin begun. If the
condition has existed for any length of time and the patient is weak
and exhausted, stimulants are indicated.
+Lysol+ is a saponified phenol, and possesses some germicidal power. It
is used in strengths of 1 to 3 per cent. solutions.
+Creolin+ is mildly germicidal and is used a great deal in from 2 to 4
per cent. solutions.
Both lysol and creolin act very much like carbolic acid, but neither
possess its irritating qualities.
+Formaldehyde Gas+ is an active germicide and very valuable as a
disinfectant. It is used in the shape of formalin which is a 4 per
cent. solution of the gas in water. This agent is very irritating to
the normal tissues in the stronger solution, but a 2 per cent.
solution of formalin may be used for the sterilization of the hands,
instruments, etc.
The formaldehyde fumes are employed for the disinfection of clothing,
rooms, bedding, and also for the sterilization of catheters. The fumes
of the gas are very irritating to the mucous membrane and when this
agent is used for the disinfection of rooms, every crevice and crack
must be tightly sealed to prevent the escape of the gas.
+Iodoform.+ The action of iodoform is not due directly to its ability to
destroy germs but to its undergoing decomposition in the presence of
moisture, liberating iodin and thus rendering inert ptomains that have
resulted from the growth.
+Iodoform Powder+ is rapidly absorbed by the skin and fatal cases of
iodoform poisoning have occurred from treating burns with it.
Iodoform is also used in ointment form and in suppositories. As it is
insoluble in water it is commonly used in a 10 per cent. emulsion. The
gauze is also greatly used.
The symptoms of iodoform poisoning are: delirium; odor of iodoform on
the breath; presence of iodoform in the urine; eruption over the skin,
and finally, coma. Iodoform is also capable of producing a localized
dermatitis, with great irritation, and must therefore be used with
care on all delicate skins.
+Aristol+, a substitute for iodoform, is a compound of iodin and thymol,
producing no toxic effects and having no disagreeable odor; it does
not, however, possess the germicidal qualities of iodoform. Nosophen,
iodol, and airol are among the more recent substitutes.
+Iodin.+ This drug no doubt possesses more germicidal properties than
was at one time supposed. It is probably the most powerful
antipyogenic known. The 7 per cent. tincture is the one most
frequently used.
+Acetate of Aluminum+, or more properly, aluminium, is prepared by
adding five parts of sugar of lead to a solution of five parts of alum
in 500 parts of distilled water. Burow’s solution, see page 35, is
chiefly employed as a wet dressing.
+Chloride of Zinc+ in a solution of 15 to 30 grains to the ounce, has
marked antiseptic properties, but it blanches the tissues when applied
to infected wounds.
+Sulphocarbonate of Zinc+ is less irritating than the chloride of zinc
and is of the same value as a germicide.
+Peroxide of Hydrogen+ when used as a 15 volume mixture or diluted,
seems to have a direct action upon pus generation by destroying
microorganisms of the pus. It is frequently employed for sterilizing
abscess cavities, and for hastening the separation of necrotic tissue.
This agent has also a marked hemostatic power and is used to some
extent on this account in nose and throat work. Its hemostatic power
is also observed in bone cavities. Care should be taken never to use
it unless there is a free exit, as it increases rapidly in volume
after coming in contact with dead tissue or pus, and serious accidents
have happened from its improper use; for instance, if it is injected
into an abdominal sinus where free escape is not provided for, the
distention will result in ruptures of the sinus and infiltration of
the surrounding tissues; possibly of the peritoneal cavity. The
distention produced by it is also quite painful and therefore only a
small quantity, or a much diluted solution should be introduced into
cavities.
+Boric Acid+ is not very actively antiseptic, but even in a saturated
solution it is not irritating. Where bichloride or carbolic dressings
have produced irritation of the skin, or burns, a boric acid ointment
is a very satisfactory substitute.
+Salicylic Acid+ is an antiseptic of value. It is generally used in the
form of an ointment. It is but slightly soluble in water.
+Potassium Permanganate+ by its rapid liberation of oxygen, acts as an
antiseptic of proven merit for the disinfection of foul wounds and
ulcers. It is also used satisfactorily for disinfecting the hands in
preparation for operations, in the form of a 5 per cent. solution, any
stain being removed later by a saturated solution of oxalic acid.
+Alcohol+ possesses marked antiseptic properties and is one of the best
agents for the sterilization of the hands of the surgeon, and for the
skin of the patient. A 60 or 75 per cent. solution of alcohol is much
more efficacious as a skin disinfectant than a 95 per cent. solution.
This is because the purer alcohol is much less penetrating than the
dilute. It is also used when diluted with water, one part to four, as
a dressing for granulating wounds. It is efficacious in limiting the
action of carbolic acid, when this agent has been applied in full
strength.
It is a useful agent in which to store certain materials such as
ligatures, sutures, etc.
+Silver Nitrate+ possesses undoubted antiseptic properties, and
solutions of varying strengths are decidedly antiseptic. These
solutions are from 5 grains to the ounce, to 60 grains to the ounce.
The solid stick of nitrate of silver is used for destroying exuberant
granulations. Among the different silver preparations on the market,
protargol and argyrol are the best known. Both of these are
extensively used in the treatment of inflammations of the mucous
membranes.
The unguentum of Crede, is an ointment of silver which is used in
cases of septic infection and also in localized inflammations. From 15
to 45 grains of silver can, in this form be rubbed into the skin. It
is absorbed and undoubtedly exercises an antiseptic influence on the
infecting microorganisms.
+Saline Solution+, or normal, or isotonic salt solution, as it is called
because of its close approximation to the blood serum, consists of a
solution of 7 per cent. of sodium chloride in plain sterilized water.
Roughly speaking and for ordinary purposes, this solution can be made
by adding an even teaspoonful of ordinary table salt to one pint of
boiled water and then reboiling the mixture.
It can be stored for a limited time in sterile glass jars, which are
sealed with sterile cotton. The jars can be heated to whatever
temperature is required for use. This solution is the one which is
generally used for irrigating wounds and cavities; it is
non-irritating and possesses no antiseptic quality. When a moist
dressing is desired there is no solution comparable to it, largely
because of its non-irritating quality. It has at times a slight
irritating effect upon the kidneys and when large quantities of it are
used it is better to dilute it.
+Pure Oxygen and Ozone+ have been used, and the latter is more
effectual. It has been found that oxygen but slightly retards the
growth of bacteria, but both ozone and oxygen produce a hyperemia, and
retard the growth, especially of anaerobic organisms. Pure oxygen in
the abdominal cavity produces a marked hyperemia and a leukocytosis.
Ozone has been put to some practical use in this country but the
results have not been sufficiently studied.
+Sunlight+ has a marked retarding effect on some bacteria and actually
destroys them. The anthrax spore is said to be killed very promptly by
exposure to strong sunlight and it is claimed that the tubercule
bacillus is slowly destroyed by it.
+Electricity and the X-rays+ also produce a marked retarding effect on
the propagation of certain microorganisms.