alternate post title~ "Iodine or Amputation?"
source: "Boston medical and surgical journal, Volume 164, Issue 2",
PARIS LETTER.
Tincture Of Iodine As A Surgical Antiseptic.
~From Our Special Correspondent
Paris, April 11, 1911.
Mr. Editor: One of the most surprised preparations in materia medica at the present moment must be our timehonored acquaintance, the tincture of iodine, and there is no gainsaying the fact that it has sufficient grounds for a meditation on the uncertainty of the things of this world. During all the earlier half of the last century this familiar reddish-brown liquid was one of the most important remedies in medical practice, so much so that in 1855 a certain Boinet published a large volume of eight hundred and thirty-five pages about it, entitled "Trait d' Iodotherapie." Already at that time its remarkable antiseptic properties had been noted; fetid pus had been seen to lose its noxious qualities under its influence, and compound fractures had been found to heal without any of the terrible complications so frequent in those times when treated with tincture of iodine. In a word, it seems as though at that period the antiseptic era was on the point of being discovered, in connection with this preparation, some twenty years before the Pasteur-Lister day. The opportunity was there; all that lacked, apparently, was the man with sufficient perspicacity to descry the great discovery that was staring him in the face. That man, however, was not forthcoming. The reign of phenol, sublimate, formal and peroxide began, iodine tincture was practically relegated to the old woman's arsenal, and this marvelous preparation descended very nearly to the level of arnica and chamomile tea!
This period of oblivion lasted for nearly forty years, but now, by the agency of one of those disconcerting turns of the wheel of fortune, tincture of iodine has once more been raised to a position of real eminence in medicine, and suddenly — within the brief space of a couple of years. In this short time it has not only regained the rank in the medical world that it ought never to have lost, but its penetration into the masses has been so deep that it has attained even to such remote regions as the cerebral substance of society women. One of them got her finger-end caught in the door of her carriage the other day and gave it a pretty lively squeeze, producing a small wound par eclatement. When I arrived I remarked in scornful tones, "What in the world did you put arnica on it for?" She was generous in her triumph, that I must allow; for of course she had a lovely chance to make some withering reply. All she said was, "Oh no! that isn't arnica; I drove to the nearest druggist and had the finger painted with iodine!" "The devil you did," thought I; "if these Red Cross lectures continue to rage throughout the land, the future of the medical profession will soon be even less roseate than it seems at present. For the idea is to me not inconceivable that within a delay that is really more or less proximate, the physician is going to have to make his choice between some of the side-branches of his calling, — electricity, radium, x-rays, or mind-treatment, — or harakiri after the scorpion method. Certainly if I had a son who was going in for general medicine, the utmost degree of sympathy at my disposal would be extended toward him, as I think he will see the time when his profession will no longer be a living proposition.
Tincture of iodine, then, has been discovered to be the most marvelous antiseptic known, and, — details that enhance its virtues many times over, — one whose use is simplicity itself, that can be found anywhere and that can be safely put into almost any one's hands. From one point of view it has a similarity with salvarsan in that it is of particular use in very difficult cases, cases that proved almost beyond the resources formerly at our disposal. This will be referred to in a moment; for the present let me cite an instance or two that have come to my ears recently.
One of the younger surgeons here received an urgency call the other day to come at once to such and such a hospital for an amputation. When he arrived he found a man who had got his right hand badly crushed in handling wine barrels, with various fractured bones and wounds, the whole region being, of course, as dirty as possible. It had never occurred to the interne that any other treatment than amputation or disarticulation was to be considered; yet, with simple iodine paintings, this man made a perfect recovery with a quite serviceable hand.
Another surgeon friend of mine went one afternoon to see a lady patient on whom he had operated a short time previously for appendicitis. She told him that her last monthly period had missed entirely and that she was now feeling considerable pain in the pelvis. On examination he found a small mass back and to one side of the uterus, diagnosed extra-uterine pregnancy and told her she must have it removed without delay. That same; evening at ten o'clock he was called to see her again; pain had increased and her condition and appearance had alarmed those about her. The fetal cyst had evidently ruptured during the evening, the patient presented all the signs of serious internal hemorrhage and my surgical friend found himself in presence of as serious an emergency case as any one need desire, as it is not easy in Paris to get anything done in a hurry. However, by dint of heating up the telephone wires he managed to get the patient transported to a clinic and his aids assembled by one o'clock. By that time his unfortunate patient's condition was highly critical, the bleeding was evidently continuing and there was no time to lose. It is easy to conceive that with the former methods of preparing an abdomen for laparotomy, the loss of time, combined with the rough handling necessary to throughly brush and scrub the skin, might have given tliis patient the finishing touch, whereas in this instance, while the surgeon was slipping on his sterilized India-rubber gloves, the assistant simply painted the abdominal surface gently with soft gauze dipped in tincture of iodine and held in a forceps, there was not the slightest delay or mauling of the patient a rapid incision revealed an abdominal cavity filled with blood, the cyst was clamped at once, the usual means of treating severe loss of blood could then be brought to bear, and the surgeon was master of the situation. Such a case as this must, I think, be one of the surgeon's keenest satisfactions, a case in which he is authorized to feel that but for his intervention his patient would have succumbed without doubt in another hour or two. This same man operated an umbilical hernia in a dog for me the other day with the iodine process without even shaving the region; it seems that this is current practice in the experimental laboratories now.
The iodine tincture of the French pharmacies is a one in ten solution in alcohol. It should, whenever possible, be procured fresh; when old it is subject to two secondary processes whereby it becomes stronger and more likely to irritate: the development of hydriodic acid, and concentration through alcohol evaporation. The question is being studied whether it is really necessary to use this one-tenth solution; whether, for instance, this could hot equally well be further extended with alcohol to at least one-twentieth, or whether aqueous solutions obtained with iodide will not be just as efficacious.
For although it has proved to be one of the safest of all antiseptics, we all know that there are certain patients with a marked idiosyncrasy for iodine with whom small doses produce the most alarming symptoms, and in particular those of edema of the glottis. Thus in the case in point I personally have heard of one patient with whom a most distressing and persistent generalized eczema was brought on by a single application of tincture of iodine; and of another who actually succumbed from acute iodism under the same circumstances. Because, not only is the iodine being applied on normal surfaces, as in the above extra-uterine pregnancy case, or as has been done by different surgeons in emergencies when away from all facilities and they have painted their own hands in order to operate; and not only is it used on open and crushed wounds, and even on extensive denuded surfaces such as burns, but it is applied to severe solutions of continuity, such as a scythe wound, the surfaces being stitched together a few minutes later, and it is also injected into suppurating cavities or fistulas. Under these circumstances a certain amount of the iodine must remain behind; so that if an equal effect can be obtained by a less active solution, it is certainly to be desired that this point should be demonst rated as quickly as possible.
There is a trifling artifice that it is useful to know, in order to have it at one's disposal in instances when a modicum of mind-cure is necessary. Certain families keep tincture of iodine in stock and use it themselves on all occasions, just as others do their precious Pond's Extract or Antiphlogistine. One woman I know here gets Pond's Extract over from America by the demijohn, and has the most absolute faith in its virtues to cure nearly every affection her large household of family and servants presents. To prescribe to such a person a remedy that she is in the habit of using herself would simply be to lose caste in a very precipitous fashion; whereas if you sit down and gravely formulate:
Metalloidic iodine, 3
Spirits of chloroform, 30
A point that I have been turning over in my mind is whether this preparation may not be excellent for medical use, and in particular for tonsillar affections. The peculiar efficacy of iodine tincture is said to be due to its marked power of penetration, which in turn depends on its alcoholic vehicle; to be really efficacious, then, it should be applied to a perfectly dry surface, all previous cleansing by washing, soaping, etc., impeding its action. Now in the throat a dry surface could scarcely be obtained; but by first carefully wiping off the tonsillar region something approaching such a condition could be produced; besides, the tonsil is not protected by any hard layer of epidermis. I have often used in the throat a preparation consisting in one part of tincture of iodine to two of glycerine, but have never been able to see that it accomplishes very much. This is perhaps due to a peculiarity that we find in phenol, which seems to lose many of its properties, causticity, toxicity, etc., when combined with glycerine. It will be interesting to see how the tonsil reacts to pure tincture of iodine without the glycerine.
I remarked above that the tincture of iodine is particularly effective in the very worst cases, and the type of these is the mechanic or train-hand, who gets one of his extremities mashed in the course of his work. Not only do these accidents present the very worst forms of lesions, — mangled and torn tissues, open articulations and compound fractures;—but the damaged region cannot be otherwise than in the filthiest possible condition. These cases, also, are generally somewhat long in getting to the nearest help, particularly in a railroad accident out on the line. It has really seemed to me worse than useless to attempt to clean up such an affair as a mechanic's hand mashed in a machine. Will not the cleaning send into the open wounds more germs than are there already? My surgical friend assures me that by filling up all the wounds with strips of sterile cotton soaked in some antiseptic fluid, and then operating with care, patience and benzine, the thing can be accomplished; so I suppose we shall have to take his word for it. But however this may be, all doubts of the sort are removed with the iodine process. Here, the less you do the better. No cleaning at all; at the most remove fragments that are bound to go any how, and be chary about this, for I think that the longer we live the greater becomes our respect for what nature can do at a push, then paint everything, — skin wounds, fractures, — carefully with the tincture, not being afraid to go over a surface more than once, and pushing it into every nook and hole. Over that, chiffonmr a lot of light gauze, then some cotton-wool, and a bandage, and the trick is done.
Nothing simpler could possibly be desired, and a Trousse of this sort, with brief directions, could easily be on every train and in every factory. Strange to say, the pain connected with the application is really insignificant; it can be spread over large burns with equal results. Fancy the revolution this process is going to effect in first-aid ambulances near the firing-line in war time!
What happens, then, after such a dressing as this? The tincture appears to give rise to a profuse serous discharge, which is taken up by the chiffonnee gauze, which must not be protected by any hermetic tissue. Usually such a first dressing can be left in place for twentyfour hours, though of course, if the discharge soaks through the gauze, this can always be removed, and as often as desired. The next day the dressing is changed and the tincture applied again. This daily change is continued so long as the discharge lasts, which is, as a rule, from four to five days. The surfaces then become dry and the dressing and painting need only be done every three or four days.
The cases of recovery that have been reported under this treatment sound really more like fairy tales than serious surgical work. What do you think, for instance, of a compound, comminuted fracture of the leg that had been carefully cleaned, reduced and sewed up by a surgeon, but when his effects failed lamentably and gangrene set in, this was opened by another man, thoroughly painted in every corner, and recovered!
~"S"
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