RECORD OF MEDICAL SCIENCE.
PATHOLOGY AND PRACTICE OF MEDICINE.
On the application of Tincture of Iodine as an ectrotic remedy in Small
Pox. By James Crawford, M.D., Professor of Clinical Medicine,
M Gill College, and Physician to the Montreal General Hospital.
It is now upwards of nine years since I first recommended the appli-
cation of tincture of iodine as an ectrotic remedy in small pox, and al-
though I observe that the suggestion has been noticed by Dr. Copland,
in his Dictionary of Medicine, and by Dr. Dunglison, in his work on
Therapeutics, and also by some others in the United States, I would ne-
vertheless desire again to draw the attention of the medical profession
to the benefit that a more extended experience has convinced me would
follow a general application of the remedy.
Epidemics of the dangerous malady of small pox, have been fortunately
rare amongst us, and therefore the opportunity of further testing this
remedy had not been afforded me, till the latter end of the last year, and
earlier months of the present, during which period I have had occasion
to treat, both in hospital and private practice, several cases of very grave
variolous disease, and would desire to lay my further experience before
the profession, anxious that a fair trial and just estimate of the applica-
tion should be made, while I feel fully confident that it will maintain
the reputation I have deemed it deserving of. I would here appeal to
those who have seen much of the natural small pox, or its effects, how
few cases escape pitting and unseemly scars, when the disease is allowed
to run its course without interference, and I would ask, how many at-
tempts have been made in consequence, to supply an ectrotic remedy,
and how difficult of application, or disagreeable, and even inefficacious,
are any that have been hitherto recommended. The Herculean under-
taking of cauterizing the several individual pustules, in severe cases,
quite precludes its application. I have reason to think the compound
tincture of iodiue, a very powerful and efficacious remedy, which has
been tried with very satisfactory results in the Montreal General Hos-
pital, by my friend Dr. Campbell, but from my being under the impres-
sion that the addition of the hydriodate of potass caused more pain, I
have not employed this form. The disagreeable mercurial mask, the
inefficacious covering of gold leaf, cotton, or collodion, are now in a
great measure laid aside. I stated formerly, on the occasion of my first
suggestion of this application, in the Medical Gazette published in this
city in 1844, that I was led to try it in small pox from the very marked
benefit I had derived from its use in erysipelas, and various other cu-
taneous diseases, for several years previously. I was then satisfied of its
anti-plilogistic powers and soothing effects, and trusted that a more gene-
ral employment of it in variola would establish its claims to general
confidence.
During the late epidemic of variola, I have had several opportunties
of trying its powers, and my cases have been observed by many mem-
bers of the profession, to whom the issue has afforded every satisfaction.
I have reason also to know, thatseveral medical practitioners have follow-
ed my example with success, while others have made only a very imper-
fect and insufficient occasional application, which neither could afford a
satisfactory result, nor determine the advantages derivable from it.
I have been favored with the opinion of several physicians of this city,
of the highest standing in the profession, on the advantage of using this
remedy, which I subjoin.
The application I have used is a saturated solution of iodine, in spirit
of wine, which is to be brushed freely over the face once or twice daily,
from the earliest day of the eruption that is practicable, and continuing
the repetition of the application daily, or oftener, during the period of
the maturation of the pustules. The earlier the application is commenced
the more efficacious it proves. The inflammatory and ulcerative processes
are controlled, and the intolerable itching relieved, by which means
scratching, and its evil consequences, are obviated. For some time I
was disposed to confine the application to the face, as being the part
most disposed to ulceration and pitting, as well as that most desirable
to be preserved from marks. I have, however, on many occasions ap-
plied it to various other parts, for the sake of experiment, or contrast,
and also to relieve the intolerable pruritus, and have even extended it
over nearly the whole body, at the patient’s desire, without any evil
consequence or inconvenience from the most extended application. The
relief it affords to the itching, (if it conferred no other boon), would of
itself be a sufficient recommendation of the application. Its antiphlo-
gistic and febrifuge properties, however, are very manifest, and I have
no doubt modify, and moderate the fever, and thereby operate in a most
salutary manner. The medical treatment I have combined with it is so
simple and mild, that a great deal cannot be attributed to it; being
merely small doses of calomel and Dover’s powder occasionally, during
the day, and night, as a sedative. When pits are left, I have observed
that they principally occur on the nose, and I am inclined to think that
this may in some degree be owing to the insufficiency of the application
to this sensitive part, or from the disagreeable vapor causing irritation
of the Schneiderian membrane, or eyes, which makes the patient more
desirous to escape from its application; but even this inconvenience may
be easily obviated, by keeping the eyes shut, and, if requisite, stopping
the nostrils.
The immediate effect of the application is pain, which is more com-
plained of by some than by others. It speedily subsides, and gradually
abates in severity, after the first few applications ; and the relief to the
itching it affords is so gratifying to the patient, and the effects so mani-
fest to the friends, that they always remark the contrast of the parts
“ painted,” with those left “ unpainted and frequently request a fur-
ther extension of the application. I will record very briefly, a few of
the cases, some of which were treated in the Montreal General Hospital,
and some in my private practice :—
Case 1.— Variola Discreta.—J. H., aged 19, admitted into the Mon-
treal General Hospital on the 31st October, 1852, under my care, on
the third day of a variolous eruption, which covered the face and limbs
very profusely, although distinct. The face was swelled, the tongue
covered by a pustular eruption, and there was salivation. The initiatory
fever had been severe. He complained much of the itchiness of the face,
his pulse was full and frequent. He was ordered to be painted over the
face, and to have small doses of calomel and Dover’s powder 3 times a-
day. One of his arms was also painted for the object of comparison with
the other. These parts soon exhibited a marked contrast from those left
unpainted. The pustules remained small and formed thin scabs, which
fell off early, and left the subjacent parts free from pits. Although this
case was grave, there was no bad symptom. It was seen by several
medical gentlemen, who expressed their satisfation and conviction of the
beneficial effects of iodine, and that it had prevented pitting and marks.
Some weeks after convalescence, his face was quite smooth. The patient
was uncertain whether he had been previously vaccinated.
Case 2.—Semi-confluent Small Pox.—.E. B., aged 19, admitted into
the Montreal General Hospital, 30th November, 1852, on the second
day of variolous eruption, which had been preceded by high fever,
vomiting, epigastric and lumbar pains. It was copious on the face,
which was much swelled, his spirits good, slept tolerably well, and with-
out delirium. Eruption became very profuse over the limbs, and con-
fluent on some parts, areola bright. The fever was moderate. Ordered
to be painted with tincture of iodine, and to have the calomel and Dover.
The crust formed a complete mask over the face, but was thin. The
buccal mucous membrane did not appear to be involved in the eruption.
The application was made daily, and the case progressed favorably.
There were no depressions or marks left on the face. The iodine was
also applied to different parts of the body to relieve the itching with
very satisfactory results. Did not know whether he had been previously
vaccinated.
Case 3.—Semi-confluent.—M. M. aetat. 7, (private patient,) to whom
I was called on the second day of eruption, which had been preceded by
smart fever and vomiting. The eruption was profuse, but distinct, over
the face and extremities, with few pustules on the body, the mucous
membrane free from it. The patient was said to have been vaccinated.
She was ordered, as usual, to be painted. She did not make much com-
plaint of the application, although of such tender years. The pustules
on the painted part remained small and flat, quite unlike the other parts.
Several pustules on the limbs became confluent—the areola rosy. Ou
the 9th day, some of the pustules on the limbs had a hemorrhagic appear-
ance, the scabs on the face were thin, and the secondary fever light.
There was little swelling of the face, and no salivation. About the 10th
day, she was attacked by rheumatic pains and swelling of the ankles and
knees. Her bowels became disturbed for some days ; an abscess formed
at the ankles, elbow and axilla; these were discharged. Her strength
was supported from an early period by nutritious diet—beef tea, arrow
root, wine and quinine. About the 21st day of the eruption, she began
to cough, accompanied by a mucous rale, and profuse expectoration, with
great dyspnoea at intervals. An emetic, a sinapism, and pediluvium re-
lieved her for the time. The mucous secretion continued profuse, and
her strength failed, and she sank on the 31st day. There were only a
few small superficial pits on her face, which would not have been very
observable had she lived. The irritation from the rheumatism, and the
discharge from the several abscesses, together with the profuse tenacious
bronchial discharge, and consequent orthopnea, carried her off. The
case would otherwise have been very satisfactory, although the applica-
tion was commenced later than was desirable.
Case 4.—Semi-confluent Variola.—Miss E. M., aged about 18, (pri-
vate patient,) after a smart fever, accompanied by severe epigastric pain,
intolerance of light, redness of the conjunctiva, and slight sore throat,
an eruption of papulae appeared on the face and wrists. I saw her on
the second day of eruption, when it was thickly out over the face and
limbs. It soon spread over the whole body, and was very profuse, but
kept distinct, except at a few parts. The iodine was applied to the face
and back, with so much relief to the patient, from the itching, that she
on many occasions made her sister apply it to various parts ; in fact I
might say it was used all over her body, which circumstance she con-
fessed after her convalescence. The secondary fever was severe, accom-
panied by much gastric irritation. There was also a good deal of suf-
fering from a rheumatic affection of her wrists and ankles, which render-
ed her very helpless. She, however, got well, without any further
troublesome symptom. The scabs were thick, and remained a long
time on the right side of her nose, which (as was remarked by her sister)
had been less assiduously painted, from that side being turned to the
wall, and inconvenient to get at. On this part there remain several
small superficial depressions, and the forehead has some very slight
marks, only discernible en profile, which I expect will not be perceptible
in a little time. The face is pale and without any stain, and generally
quite smooth. The case was very severe and was seen by several medi-
cal gentlemen, who expressed their satisfaction of the efficacy of the
remedy. It is doubtful if this patient went through regular vaccinia.
Case 5.—R. C., setat. 15. I was called to this case on the 5th day of
the eruption. The girl had been under the care of a medical practitioner,
who had not applied the iodine, although it was suggested to him by
the priest, who had seen its advantages in the previous case. The erup-
tion over the face was flat and ill-filled. Although profuse, it was dis-
tinct over the body. She was a delicate, dwarfish girl, subject to splen-
itis. At the period I saw her, she was very weak, depressed in spirits,
and sleepless. She was ordered a small quantity of wine and water, and
beef tea frequently, calomel and Dover’s powder, and to have the face
painted. Although the expectation of benefit was much lessened, by
the late period of the application, it caused, as usual, some pain, but at
the same time afforded so much relief from the itching, that she fre-
quently desired its reapplication. The eruption became confluent on
several patches on the limbs ; but little eruption on the body. The
face swelled, and there was salivation. The scab on the face formed a
complete mask, but not very thick. Her spirits revived, and her strength
was maintained by wine and soups. Her feet, legs and wrists became
painful and swelled. She, however, recovered well in about three weeks.
There remain several small superficial pits on the face, which could not
well be otherwise, as the application was so late in being applied, and a
mark of a scratch she made before the iodine was applied. But they
are evidently very much modified even by the late use of the remedy,
and the relief to the itching derived from it was manifest, from her often
desiring its application and extension over other parts. Several boils
took place on different parts, but she soon recovered. This patient had
never been vaccinated. Her eldest sister was vaccinated during the
progress of the case, and passed through the stages, in a satisfactory
manner.
Case 6.— Variola confluenta.—-A. A., aetat. 15, a delicate looking
boy, had never been vaccinated, nor any of his family, three of whom
were vaccinated on the occasion of my being called to see him, and all
passed through the regular stages in a satisfactory manner. This boy
had, a short time before his illness, received a visit from a young friend?
just recovered from an attack of variola. The primary fever and epigas
trie pain were pretty severe. The eruption was profuse over his face
and extremities when I saw him on the second day. The iodine was
applied in an unsatisfactory manner, from the interference of the patient
and his mother. The eruption soon became very profuse, and confluent
on many parts. The tongue and fauces were covered by ulcers; the
voice scarcely audible ; some cough and expectoration. The iodine pro-
duced such a soothing and satisfactory effect, that he soon desired its re-
application, and it was extended to various parts to relieve the itching.
The case, although very severe, went on well. Secondary fever was
high, and there was much distress from the mucous membrane of the
larynx, and from the pustules on the scrotum, and pains of his hands
and soles of his feet, which are covered with pustules. He also suffered
from rheumatism of the ankles and wrists, which were much swollen.
The Dover and calomel afforded him relief and sleep at night. Beef
tea and arrow root were ordered from the earliest day, and latterly wine
and quinine. He was convalescent in three weeks, and able to sit up, in
good spirits, saying he could dance with nurse, if the sores on his feet
did not prevent him. Scarcely a trace of pit or depression being left
on the face, whilst the parts unpainted showed numerous pits. On the
23d day from the appearance of the variolous eruption, an erysipelatous
blush appeared on the forehead, and a similar one on the knee. An
abscess formed in the axilla, and also on the eyelid and ankle. His back
also became painful, and affected by erysipelas, and a smart fever super-
vened. His bowels discharged large quantities of ochrey looking fer-
menting and very offensive evacuations, for three or four days, when the
fever and erysipelas subsided. About the 30th day the fever returned
and assumed a typhoid type ; dark, black, dry tongue ; muttering de-
lirium, subsultus tendinum, &c. &c. He continued in this precarious
state for a week, when he became quite intellectual, and able to tell his
wants, and good hopes were entertained of his recovery, when suddenly,
after two days of this favorable state, he was seized with dyspnoea and
hurried breathing, and died in a few hours. The treatment is omitted,
as not being an object on the present occasion. The most satisfactory
results were observed to attend the use of the iodine, both by allaying
the irritation and preventing marks, scarcely any being perceptible. This
case was seen by Dr. Campbell, in consultation, and by others, to witness
the effects of the remedy.
I have treated several other slighter cases, in which the iodine was
used in all with marked benefit in relieving the itching, and in all pro-
bability preventing pitting, as even in cases where the eruption is sparse,
pitting may follow. I have also seen several severe cases in which it
was tried in the Montreal General Hospital, under the care of other
physicians, with the most satisfactory results, a summary of which ac-
companies this notice.
I think I may add without overrating the advantages of the applica-
tion, that being a powerful antiphlogistic, while it lowers the inflamma-
tory action, it thereby controls the general fever, and moderates the
risk and mortality from the secondary fever.
The two fatal cases which I had during the present epidemic, being
evidently rendered so by other causes than variola, namely, in one, by
erysipelas and typhus fever, supervening during convalescence, on the
thirty-first day after the appearance of the variolous eruption. The
other fatal case was carried off on the thirtieth day by continued irrita-
tion, and wasting from rheumatism, abscess and bronchitis, with profuse
mucous discharge.
I have very great pleasure and satisfaction in adding the testimony of
Dr. Bergin, of Cornwall, to the beneficial effects of iodine in small pox;
who had in 1849 an opportunity of using it on a very extended scale,
such as rarely is the lot of any individual in this country. The follow-
ing summary, which is founded on returns made to the Hon. Colonel
Bruce, Superintendent General of Indian affairs, is very brief, but it
comprehends all that can be desired in support of the claim of this ap-
plication, as an cctrotic remedy. Dr. B. had witnessed the early ex-
periments I had made on this subject, during his pupilage in Montreal,
and gladly availed himself of the unusual opportunity he had, when em-
ployed by the Colonial Government, to afford his professional aid, to a
tribe of Iroquois Indians at St. Regis, on the banks of the St. Lawrence.
He briefly states, “ I have treated 300 cases of small pox among the
Iroquois Indians at St. Regis, during an epidemic in 1849. Of these
200 were very severe, either confluent or partially so, and to whom
iodine was applied, as follows :—The whole face was painted, daily from
the earliest day that it could be done in eiglity-five cases of confluent, or
semi-confluent small pox, out of which only seven exhibited any marks,
and these were slight. Half the face was painted in seventy cases of
grave disease; of these, sixty-one were free from any marks on the
painted side, five were badly pitted, and four slightly, on the painted
side, while the unpainted side had numerous marks and pits, exhibiting
a very striking and marked contrast, fifty cases were painted at different
periods, during the maturation of the pustules, upon which the tincture
did not appear to have much influence. There were eight cases of
variola modificata. Twelve of the cases terminated fatally, one of which
was of an haemorrhagic type.
I need scarcely add, that I am fully convinced of the beneficial effects
of tincture of iodine, not only as a powerful ectrotic remedy, but also as
a very efficacious means of controlling the irritation and itching, and
thereby not only relieving the suffering of the patient, but also re-
moving the involuntary and irresistible disposition to scratch, and the
consequent production of wheals and scars. I am also of opinion that
it moderates the febrile action, and thereby the danger. I have used a
small quantity of hydriodate of potass to aid in the solution of the
iodine.
1 freely confess that 1 conceive 1 would not be doing justice and my
duty to my patient, if I omitted to apply this remedy on any future
occasion. It should be commenced at the earliest day of the eruption,
and continued daily for a week. I may add that I have been applied
to, on many occasions, for iodine, by Indians from the Racquett River,
to whom I could not afford further aid. The cases were generally of a
very grave type, and it appears to me that the Indian constitution, like
the Negro, suffers severely from this malady.”
Besides the seyeral medical gentlemen who saw these cases, during
their progress, and subsequently after convalescense, I had the pleasure
of showing such of the patients who had passed through the ordeal as I
could meet with, to Dr. Marshall Hall, of London, during his visit to
Montreal. Two of these (numbers 4 and 5) will be admitted not to
have been selected as favorable specimens, not only from their severity,
but also for one not having been seen by me till the 5th day, conse-
quently not having had the application made till a late period; in fact
these cases presented more marks than any other I had. Dr. M. Hall
has kindly favored me with his opinion as follows :
From Marshall Ilall, M. D., F. R. S., &c.
I have seen with much satisfaction several patients who had been af-
flicted by variola, and treated by Dr. Crawford by the application of the
tincture of iodine. The superficial pits I noticed appeared to me to be
so numerous and crowded, that confluence and deep and lengthened
scars must have taken place, but for the effectual abortive treatment by
the iodine; and I cannot but think this a most valuable application in
such cases.
Extract from a note from W. Henry, Esg., M. D., Inspector General
of Military Hospitals.
Since I received your communication on the use of tr. iodine as an
ectrotic in small pox, I have directed it to be used, and careful minutes
taken, in about a dozen bad cases of small pox in Military Hospitals,
several of which I watched myself. I also observed the practice last
year in two of your patients in the Montreal General Hospital.
In some of the military cases, the tincture was employed, but in the
greater number a liniment was used, composed of powdered iodine and
olive oil, in the proportion of a drachm of the former to an ounce of oil.
I prefer this to the tincture for external use, because it adheres to the
skin better and is not so easily evaporated.
I entertain no doubt of the great value of iodine in this practice. It
appears to check the deepening and developing of the pustules, to pre-
vent their confluence, and to lessen materially the cutaneous inflamma-
tion in the interpustular spaces. Though last, not least, by stopping the
deepening of the pustules it prevents subsequent disfigurement by pock-
marks.
Extract from a note from P. W. Maclagan, M. D., Surgeon, 20th
Regiment.
I have employed the tincture of iodine in four cases of small pox, one
of them semi-confluent, the others confluent and hemorrhagic. One
which you saw terminated fatally, but the poor man felt great relief
from the application, and earnestly begged its repetition more than
once.
The others are decidedly less deeply marked than might have been
expected. Indeed, the superficial traces which remain will, I doubt not,
disappear entirely. One of my patients complained a good deal of the
smarting, for an hour or two after the iodine was applied; but the re-
mainder made mention only of the smell of it—rather I suspect the
irritation of the mucous membrane produced by the vapor.
From George IF. Campbell, A. M., M. D., Professor of Surgery,
McGill College.
Within the last two months I have tried iodine as an ectrotic in small
pox, in the Montreal General Hospital, in four cases; two Of them
severe cases of confluent small pox, in which the face and eyelids, on
the second day of the eruption, were greatly swollen, and entirely
covered with incipient pustules. The tincture used was composed of a
drachm of iodine to the ounce of alcohol, a few grains iodid. potasse
being added to dissolve the iodine. The application was repeated once
a day for four or five successive days. No suppuration occurred on the
face, and when the mask, formed by the iodine scaled off, there was no
pitting, and the face presented a marked contrast to the skin on the
limbs and body being perfectly smooth and healed over, long before the
scabs had separated in other parts. In neither of the above cases did
the constitutional symptoms correspond with the severity of the eruption.
There was no secondary fever and I have no doubt the disease was
greatly modified by the ectrotic treatment. In conclusion I would re-
mark, that I think the strong tincture of iodine employed more effectual
and less painful than the ordinary tincture.
From A. Hall, M. I)., Professor of Materia Medlca, McGill College.
I have employed tincture of iodine freely both in private and Hospi-
tal practice, and from the general good results which I have witnessed
following its timely application, I deem it an essential part of the treat-
ment in that complaint. Of the various ectrotics which have been sug-
gested, I consider it incomparably the best.
Shortly after you first suggested its use, I admitted into my wards at
the Montreal General Hospital, a young woman, laboring under a severe
attack of variola secreta. Doubting the efficacy of the tincture, but de-
sirous of testing its value, I ordered its application to the left side of
the face, neck and arms. On recovery, these parts presented scarcely
the appearance of a cicatrix, while the collateral portions were severely
marked by the disease. I regarded this as an unequivocal demonstra-
tion of the value of its practice, although I deeply regretted afterwards
that my doubts had suggested such a mode of experiment.
I agree with the view which you have expressed that success depends
on as early an application of the tincture as possible, and a steady repe-
tition of it during the maturating period of the disease. In females I
have extended the application of it, over the breast, as well as over the
face, and I have been rarely disappointed in my expectations.
I regard the use of iodine as a decided improvement in the treatment
of small pox; and I am happy to bear my testimony to its value, and
to the obligation under which society is to you as its suggester.