Boston Medical and Surgical Journal 111(11): 257-258 (September 11, 1884)

ANTISEPTIC THERAPEUTICS

AT the recent meeting of the Medical Congress at Copenhagen the subject of antiseptic medication was discussed by Ewald, Jaccoud, Bouchard, Grancher, Liebermeister, and others. Ewald was inclined to accord a great value to the discovery by Koch of the bacillus tuberculosis; it had certainly been of great diagnostic importance, and was likely to have an influential bearing on therapeutics. Jaccoud did not understand that Koch's discovery had added anything to the therapeutics of phthisis. If we take account of the fact that the transmissibility of the disease had been established by Villemin, and that the profession was in possession of all the hygienic and medical means of precaution before Koch announced the results of his labors, it will be seen that the discovery of the bacillus has been barren of any useful therapeutical fruits.

Guttman thought this a very narrow and unmedical view of the subject. Always when we have bad clearer notions of the causation of diseases improvement in therapeutics has followed. We are still, unfortunately, in the experimental period, as far a. the treatment of phthisis is concerned, and the discovery of the bacillus is too recent an event to warrant as in denying that it is to have an important influence in the therapeutics of tuberculosis.

Subsequently at this session Bouchard gave an interesting address on Antisepsis in Medicine. The only kind of therapeutics, he said, that is really curative is pathogenic therapeutics, for this aims at the cause. Today we possess, for a considerable number of infectious diseases, a pathogeny which is positive. A new tentative, then, in the direction of pathogenic therapeutics is warranted, this shall be antiseptic therapeutics.

The value of surgical antisepsis is practically undisputed, but, the notion of medical antisepsis has not been so readily entertained. We are told that the infectious element being in the intimate recesses of the organism, it is necessary, in order to reach it, to impregnate the entire organism with the antiseptic substance, which must equally modify the human cells and those of the ferment, and which will kill the patient before killing the microbe.

Bouchard thus states the fallacy of this argument:—

  1. There are substances innocuous to man which are destructive, if not to microbes in general, to certain microbes. Oxygen, indispensable to man, prevents life in the case of a host of ferments; salts of silver in doses which are without effect in animal organisms arrest the development of an aspergillus.
  2. There are medical diseases such as dysentery, cholera, and diphtheria, where the infectious agent is at least for a limited time, on the mucous surfaces and can be reached topically without impregnation of the entire economy by the antiseptic substance.
  3. Medical antiseptic therapeutics does not propose to kill the microbe (as has been falsely represented), but only to stay its pullulation. In fact, when in infectious diseases the victory is decided in favor of the ferments it is because the latter are incessantly renewed, because new combatants, always more numerous, succeed those that perish in the struggle for existence against the animal cells. In the higher organisms, animal or vegetable, a simple change of environment, of climate, suffices to make them lose their fecundity without compromising their existense. The example of sheep belonging to the department of Beance, which become refractory to charbon when they have been transported for a certain time to Algiers, gives us reason to hope that even slight modifications in the human infected organism may prevent the indefinite multiplication of certain microbes which have invaded it.

Certain clinical facts go to confirm these views. All antithermal medicines are also antiseptic. Quinine, which in typhoid fever may reduce the temperature three degrees and more, does not lower the temperature in a healthy individual. It is even without action in certain fevers, such as attend pneumonia and erysipelas. Quinine would, appear to act, then, not so much by its physiological effect on the organism as by being noxious to certain pathogenic microbes. Phenic acid, which is assuredly antithermal, is at the same time a poison to the infectious agent of typhoid fever.

According to Bouchard's statistics, out of one hundred patients cured by the phenic-acid treatment there were ten in whom the disease lasted less than a fortnight. In one case he saw accidental poisoning by the carbolic acid cut short the disease; the temperature fell from 40 C. to 35.7 C., and did not thereafter gain a higher point than 37 C.

All the medicaments whose good effects have been vaunted in typhoid fever are antiseptics.

Clinicians show a certain obstinacy in coming back to the employment of mercury in typhoid. Serres has given the black sulphuret, Becquerel uses the blue ointment by frictions, while Salet administers calomel even to salivation.

The method of Salet has given, as reported, in Bouchard's practice, a mortality of six per cent., and a medium duration of twenty days. All the patients that have been salivated have recovered, and in these cases the duration of the disease was briefest of all.

The antiseptic treatment of typhoid fever by calomel is realized by giving this mercurial in doses of from one to two centigrammes every hour till the mouth becomes sore. Against the advisability of this method is should be said that convalescence is thereby rendered longer and more painful. Bouchard would not be understood as actually proposing an antiseptic treatment of typhoid fever, at the same time believing that medical antisepsis is theoretically admissible, and in certain cases practically realizable.

It seems highly probable that persevering researches undertaken in this direction will be attended with fruitful result.. They ought to be first pursued in the laboratory. A double direction may be given to these researches. In the case of diseases of which the infectious agent has been isolated and cultivated it would be well to test in the culture liquids the sensibility of the microphyte to divers substances called antiseptic. The same medicaments should then be tried on animals which have been inoculated with the microbes of contagious diseases to which they are susceptible. It is by the blood that the medicament must be made to reach the microbe.. Intra-venous injections, which, in the present state of science, ought to be interdicted in the human subject, seem to be the preferable means for the introduction of medicaments in animals under experimentation.

Bouchard, as the result of careful experiments undertaken to ascertain the quantities of antiseptic substances which by kilogramme of the weight of the animal will produce death, and the quantity which may be given with safety, has, in respect to many of these substances, arrived at what he calls the therapeutic equivalent of the medicament, that is, the quantity reckoned by kilogramme of the animal, which, when injected into the blood, does not determine toxic phenomena, but beyond which poisoning takes place. He has made this estimate in the case of seventeen antiseptic substances, and has shown that if you associate the proper therapeutic equivalents of several of these medicaments, the antiseptic action of the mixture is augmented more than its toxic action, hence there is an advantage in giving several antiseptic remedies together. In speaking of cases where the infectious element primarily occupies the surface of organs, Bouchard thinks that medical antisepsis has accomplished sufficient to warrant the expectation of greater success in the future.

It has not yet done in diphtheria all that has been expected of it, through lack of processes which enable us to act with sufficient energy on the air passages; it has been applied blindly to cholera, but it has shown itself sovereign in certain arthrites, in certain pleurities, and in dysentery.

For nine years Bouchard has employed antiseptic medication in the treatment of the complications which arise in the progress of typhoid fever in consequence of intestinal putrefactions. It is relatively easy to introduce into the digestive tube an antiseptic substance, insoluble or but little soluble, so that not being absorbed it may reach the extremity of the intestinal canal; moreover, the medicament not being absorbable cannot produce, even in large doses, a toxic effect in the economy. In having to choose between salicylate of bismuth and iodoform, he has preferred iodoform, which, associated with charcoal, has a wide range of action, and by reason of its extreme division permeates every portion of the mucous membrane, becoming thoroughly mingled with the contents of the intestines.

Sixty centigrammes of iodoform dissolved in one hundred cubic centimetres of sulphuric ether is mixed with one hundred grammes of wood charcoal powder. After evaporation of the ether the iodoform charcoal preparation is suspended in one hundred and eighty grammes of glycerine, and a tablespoonful of this mixture in a half tumblerful of some kind of drink is given every two hours.

For nine years M. Bouchard has been in the habit of giving in typhoid fever wood-charcoal powder internally in quantities of one hundred grammes a day (or a little over three ounces), in ten doses. His object has been not to act upon the typhogenous agent in the blood, nor even to oppose the intestinal putrefactions, so much as to prevent the absorption of the products of these putrefactions by fixing them to the charcoal, the daily dose of which represents a surface of at least sixty square metres. The fecal matters not only lose their fetor, but are absolutely inodorous, and give by filtration a colorless liquid. It is not only the odorous and coloring matters which are fixed by the charcoal, it is also those alkaloids analogous to the ptomaines whose existence in normal fecal matters he has demonstrated since 1882, and which abound in proportion to the activity of the intestinal putrefactions. These alkaloids add their toxic power to that of the other putrid products, and cause even normal fecal matters (and for a stronger reason those of typhoid fever) to become a permanent source of danger, which is only kept in check by the action of the renal emunctory. It is necessary to watch the evacuations to see that the charcoal does not accumulate in the intestines, and to give a purgative when you have left off the treatment.

"In typhoid fever," says Bouchard, "I have noted an extreme rarity of sacral eschars, and remarked that the tongue remains almost always moist. After the employment of simple charcoal I have seen the hospital mortality fall from fifteen to twenty per cent., and after the employment of the iodoform charcoal it has fallen to ten per cent. The same method of intestinal antisepsis 1 have applied to other diseases which are accompanied with exaggerated fermentation of the digestive tube; in dilatation of the stomach, for example. I have employed it also in cases where the intestinal fermentations were normal, but where oliguria or renal impermeability led me to fear the supervention of those uraemic intoxication, which might, I think, be more properly called stercoraemic.

"In conclusion, I will say, that if medical antisepsis has not thus far accomplished all that it promises, it has already realized some therapeutic progress."