CHAPTER IVPREFERRED ANTISEPTICS
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 and1-40. 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 beenused, 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 inactiveform. 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:
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 inBurnett’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.
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 notoxic 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.