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 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 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 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 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 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 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 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 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.
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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 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 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 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 antiseptic 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 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 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 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.