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ESSAY

THE EFFECTS OF IODINE,

ETC. ETC.

LONDON: PRINTED BY JAMES MOYES, GREVILLE STREET.

ESSAY

THE EFFECTS OF IODINE

THE HUMAN CONSTITUTION;

WITH

PRACTICAL OBSERVATIONS

ON ITS USE IN THE CURE OF

BRONCHOCELE, SCROPHULA, AND THE TUBERCULOUS DISEASES OF THE CHEST AND ABDOMEN.

BY W. GAIRDNER, M. D.

LONDON: PRINTED FOR THOMAS AND GEORGE UNDERWOOD, 32, FLEET STREET.

INTRODUCTION.

The medicine which forms the subject of the following treatise has been so lately introduced into practice, that few Physicians are acquainted either with its properties, or with the manner of using it. Almost all have heard of its effects in discussing bronchocele; and some, rashly presuming that it cannot be a drug of great power, have prescribed it without giving themselves the trouble of making any inquiry into the manner of employing it, or the dangers to which its use is liable. I have thus seen more than one Physician seriously injured in his reputation; and I have seen many patients irrecoverably injured in their health by this subtle and powerful medicine.

Not long since I was informed by a Physician, of great and deserved eminence, in London, that he had prescribed it to the extent of ten grains at one dose to a young woman. Most fortunately she was saved by vomiting. About a year ago, I was consulted on account of a young lady in the last stage of tubercular pulmonary consumption. She was attended by a Surgeon, who had bled her to a most unaccountable degree. This gentleman proposed to me the use of digitalis, which being objected to, he then proposed successively the use of hemlock and iodine. It was plain that he was about as well acquainted with the virtues of one medicine as with those of the other, and not better versed in the history of the disease he was treating. When a medicine of so much power is thus in the hands of every person, I trust I shall not stand in need of apology for having made public the following little treatise. Its materials have been for some time in my possession; and I was desirous of delaying yet a little the publication of them; but certain statements have gone forth to the world, of the great benefits to be derived from the use of iodine, while the history of its dangers has been most unaccountably withheld. It is in order to fill up this hiatus, and at the same time to direct particularly the attention of Practitioners to the proper manner of using it, with a view to its good effects, that this essay is written.

Particular circumstances have afforded me opportunities of seeing this medicine extensively used; and at the same time of witnessing the bad effects which resulted from the prodigal manner in which it was first employed. I have also made inquiries respecting its history in countries which I have not visited. The answers I have received have not been so detailed and satisfactory as I could have wished: they have all, however, more or less confirmed the observations I have made myself, or which have been communicated to me from different parts of Switzerland and France.

Some persons may, perhaps, desire to see a daily report of the different cases to which allusion is made in the following pages; but this would not have been consistent with my plan, which is rather at the present time to present an essay than a treatise to the public.

Bolton Street, Piccadilly, 4th Dec. 1823.

ESSAY

ON THE

EFFECTS OF IODINE.

The discovery of specific remedies has always, and most justly, been considered one of the most important benefits to be conferred on the practice of medicine. Much dispute has been carried on respecting their nature, but all are agreed about their existence. They have been defined by Dr. Young to be medicines which cure diseases, "without any perceptible connexion between the immediate effect and the benefit obtained." While their operation is thus obscure, the mode of their employment, and their peculiar virtues, must be subjects of much doubt and uncertainty; while the accidents to which they are liable, in common with other medicines, must occasion great embarrassment and perplexity. But from the moment their modus operandi can be connected with any known general law of the constitution, a great part of these doubts disappear, a light is afforded for directing their good effects, and a clew is obtained for tracing their injurious properties, and applying the necessary antidote. The medical history of iodine will fully exemplify the above observations.

This medicine was first introduced into practice by Dr. Coindet of Geneva. Whilst making researches for other purposes, he found that the fucus vesiculosus had been recommended by Russel in the cure of goitre. From this plant, and other species of the same family, the soda, with which iodine is generally found combined, is extracted. As the sponge, whose virtues have long been established by certain experience at Geneva, is also a maritime plant, Dr. Coindet suspected that iodine might be the active principle of them both; and by this analogy he was first led to employ it in the cure of bronchocele. The success which attended its use in the first instance was very remarkable; and it seems to have been exhibited cautiously and warily, for some considerable time had elapsed before the alarm was given of its noxious effects.

The total inefficacy of this medicine in the hands of British Practitioners, while its virtues are so palpable and evident at Geneva, that not only Physicians, but also the inhabitants in general, are convinced of their reality, had always surprised me. I was at a loss to account for testimony so contradictory. It seemed as if medicine were a science so uncertain and futile, that its plainest facts depend more on the authority of name than on the substantial evidence of observation and experiment. I lately obtained an explanation of this difficulty from a quarter in which I can place implicit reliance. It seems that the chemists are much in the habit of substituting charcoal for burnt sponge, of which an undeniable proof is the fact, that burnt sponge is sold at an inferior rate to the same article before it has undergone the process of combustion.--I may also be allowed to state in this place, that I have sent prescriptions for the hydriodate of potass to several chemists in London--that my prescriptions were said to have been made up; but that a few days afterwards, when I called at their shops, in order to examine the medicine, I discovered that they were not even aware of the existence of such a drug. If such frauds continue to be committed with impunity, the sick had better submit patiently to their pains, than have recourse to physicians, whose science is rendered unavailing for the profit of tradesmen.

It may easily be imagined, with what joy the discovery of a certain remedy for bronchocele was received in a place where that disease is extremely common. Many used it, and many were delivered from their unseemly and most inconvenient malady. But this state of things was not of long duration. Familiarity with the remedy begat too great liberality in its use, the effects of which were speedily apparent.

Iodine was then looked upon as a specific remedy for goitre. Its effect upon the system was little known and little attended to. No person seems even to have considered how it produced its astonishing results. Its efficacy, however, in the cure of goitre, was soon generally recognised. Its reputation flew over the city and neighbourhood of Geneva, and it was taken with the utmost levity, with and without medical advice. Dr. Coindet justly deplores this abuse, which was the cause of the unmerited discredit into which the remedy afterwards fell. When it had been used for some time in this manner, its pernicious effects began to show themselves; several persons paid for their temerity with their lives, and many were irreparably injured in their health. Every day brought to light some new catastrophe, the effect of iodine; and in the course of a short time its name was associated with the idea of a most intractable and virulent poison. Neither patient nor physician dared venture on its employment. It seemed to be one of those benefits held up to invite the appetite, while its use was denied us.

These melancholy consequences of its indiscriminate and lavish employment, show that iodine is a medicine of great power, and teach the necessity of watching and studying its operation. Nothing can assist us more in forming an accurate estimate of its virtues than a careful observation of the bad effects which flow from its abuse; and we shall now, therefore, proceed to consider them in detail.

These are the outlines of a very severe case. I trust that such a one is not likely to occur soon again. But if practice so daring as I have more than once witnessed in London be repeated, we may very soon see even worse accidents than the above. These statements, however, are important, inasmuch as they demonstrate that iodine is not merely a medicine of specific power against bronchocele, but that it dissipates this disease, by virtue of its very important action on the whole absorbent system. I shall take further notice of this property in a future part of my paper.

There is an effect of iodine to which I have alluded in the case just quoted, but which is so extremely common, when the remedy has been pushed to an overdose, that it deserves to be noticed at greater length. The anxiety and depression of spirits are so great and persevering as to warrant my considering them as the peculiar effect of iodine, and not the consequence of the great debility which attends the violent and inordinate action of this medicine on the constitution. It is an affection very different from hypochondriacal melancholy, inasmuch as it dwells principally on the present and has no reference to the future. Patients have generally described it to me as a sense of sinking and faintness, which were peculiarly oppressive, and I have heard them complain of it while suffering the most intense pain, as the part of the complaint which was yet the most difficult to bear. This symptom is an almost constant attendant on the violent action of iodine on the system, and frequently makes its appearance in a lesser degree when the medicine acts in a kind and salutary manner.

We have now to notice the effect of iodine on the nervous and muscular systems, and this is by far the most interesting part of our paper. It is that also on which the greatest degree of doubt and uncertainty rests.

I have seen in one case a most obstinate suppression of urine. I merely mention the fact, as I have no reason to believe it to be a common effect of the use of iodine.

This effect of iodine is frequently complicated with the choleric complaint I have already described; but it is evident that their proximate cause is different, since they also exist separately. The nervous affection is most common, if I may trust my observations, in the mobile constitutions of women; at least nine out of ten cases, which I have seen, were in women, and by far the greater number in young nubile girls. In the latter cases the disease generally excites some hysterical symptoms.

This affection differs from chorea. The patient has no difficulty in keeping the affected limbs steady, if not called upon to exert them, and in general exertion is irksome and painful. Like chorea, however, it is always attended with a constipated condition of bowels. The evacuations, also, are uniformly hard, scybulous, and dark coloured. There is certainly a considerable resemblance between the two diseases, but it would be too much to assert that what has been called their proximate cause, or their nature, is the same. Such an idea, however, has been adopted by more than one physician who has seen these cases along with myself. I mention this, not in order to give weight to the opinion, but in order to give my readers a more distinct notion of the form, which the affection we have been considering sometimes assumes. A statement of this kind is more graphical than many descriptions. Mr. Orfila, whose industry and ingenuity in the study of poisons are well known, has not neglected to examine and note the effects of iodine when given in a large dose. He gave it to different animals in the quantity of a dram and two drams. They were in general seized with violent and frequent vomiting. When the contents of the stomach were not soon thrown off, or were altogether retained, the poison was much more speedily fatal. The animals do not seem to have been affected with any other very remarkable symptom. It is stated that they were much dejected, and manifested suffering, though they did not howl, were not paralyzed or convulsed, and were not affected with any of the more violent symptoms by which poisons commonly show their action on the living body. It is plain that much light is not thus thrown on the effects of iodine when exhibited as a remedy; yet when considered along with the appearances after death, we still find a certain analogy. The stomach was generally found corroded by small ulcers of a linear form, which had eaten through the mucous coat. Those parts, also, which were most exposed to the action of the poison, were thinner and more transparent than the others, and were easily torn asunder. The mucous membrane in the neighbourhood of the pylorus was found much inflamed, swelled, and covered with a crust of coagulated lymph.

The affection of the alimentary canal which we have described above, is plainly to be ascribed to the acrid operation of iodine on its mucous membrane. I have never witnessed it in any considerable degree when this medicine had not been taken internally. But I have seen slight pains of stomach, accompanied with copious bilious evacuations, attend its external use. These never proceed to the degree of violence which marks the internal exhibition. Indeed, it is rare to see them in any considerable degree disturb the comfort of the patient. It is not thus when taken into the stomach. The case of the young lady related above, sufficiently shows its deleterious influence. I have never seen any disease of the bowels which more closely resembled the terrific descriptions given by the physicians of India, of the sufferings from the cholera of that country. Yet no medicine varies more in its effects than this. Some persons take it in large doses for a great length of time with perfect impunity; while others, from that peculiar, undescribed and unintelligible state of constitution, called by physicians an idiosyncrasy, are speedily and violently affected by very small doses. Mr. Magendie, whose accuracy is well known, states that he had swallowed a spoonful of the tincture, containing about a scruple of iodine, without any bad effect ensuing. A child, also, four years old, swallowed by mistake a tea-spoonful of the same preparation with equal impunity. These are extraordinary instances, for I have received the account of the death of a fine boy ten years old, who did not survive many hours after having swallowed the largest of the above doses. And a strong man who took this medicine, under my own care, in doses of half grains three times a-day for one week only, was very soon affected in such a manner, that, had the medicine not been immediately interrupted, the most lamentable consequences might have ensued. When this medicine is given internally, and it is often necessary that it should be thus exhibited, it must be used with extreme caution, under the sanction and observation of those who are able to watch its effects, and who are experienced in its virtues.

I have never seen a case in which the mismanagement of iodine proved fatal, and cannot, therefore, say whether its long continued use ulcerates the mucous membrane of the stomach in the human body, after the manner described by Orfila. I have no reason to believe that it does, unless the extreme violence of the symptoms, and the obstinacy of the vomiting, should by some be reckoned proofs of such a state. I certainly, however, am inclined to believe that the last mentioned symptom proceeds from inflammation and occlusion of the pylorus, which Orfila describes as the effect of poisoning by iodine.

It is a much more difficult task to discover a probable explanation of the manner in which iodine disturbs the actions of the nervous system. The rationale of diseases, even when we are best acquainted with their history, is obscure and unsatisfactory. Here it is better at once to stop short, and confess our ignorance, than, by adventurous speculation and daring theory, lay a foundation for mistakes in practice. This subject certainly presents a fine field for hypothesis, and a tempting one to a theorist. But we leave our readers in possession of the facts, and trust they will not use them with less caution than ourselves. One thing only seems probable, that is by its operation on the brain, either immediately, or through the agency of the nerves, that the effects we are considering are produced. The similarity of this effect of iodine to the mercurial erethismus, so well described by Mr. Pearson, will be evident to all, and is an analogy deserving of attention and study. I have seen many instances of gilders in Paris and Geneva affected with mercurial erethismus, closely resembling the erethismus from the use of iodine.

Our most important consideration is the cure of these painful affections. In the choleric disease the first remedy of all, and that without which we can have little hope of subduing the disease, is opium. If called early to the patient, before the bowels have yet thrown off their acrid contents, I have generally waited a little before exhibiting opium. I have done this for two reasons: First, that I might be certain of all acrid matters having been removed from the alimentary canal before the prescription of a medicine to quiet its irritation; and, secondly, because it is with great difficulty that the opium is retained while the extreme irritation of the disease is going forward. Emollient and diluting injections will in these cases be found most useful auxiliaries, both by washing out the inferior portion of the gut, and by quieting the violent action of the stomach. Hemlock and hyoscyamus sometimes succeed when opium fails. The case related at page 7 was much relieved, indeed I may say that the young lady's life was saved, by a quarter of a grain of acetate of morphium given every half-hour. Every other form of opium was tried without effect; they were not even retained an instant on the stomach. The acetate of morphium alone could be taken, and it effectually restrained the disease, which must otherwise have very soon terminated the life of the patient. This medicine has not, however, answered my expectation in other cases. I have tried various bitter and astringent medicines in union with opium, but have found them uniformly injurious during the first stage of excitement and exacerbation. Afterwards, when the disease has in some degree abated, this class of medicine will be found useful. I cannot too strongly caution my readers against the use of purgatives in such cases. However gentle they may be, their effect is uniformly and most decidedly noxious. In the first and acute period of this affection of the alimentary canal, it is almost impossible to quiet the disturbance which a purgative occasions. A remedy which ought never to be neglected is the warm bath. It will be found a most powerful coadjutor in restraining the violence of the spasms, and in moderating the perturbed action of the stomach.

I may seem to some persons to have dwelt too tediously on the poisonous properties of iodine; but let it be recollected, by those who have had opportunities of becoming acquainted with its virtues, that this medicine is as yet almost unknown to the numerous practitioners who are now daily using it; that it is a medicine of singular power and efficacy in a great class of disorders, with which the inhabitants of this country are peculiarly afflicted; that this most useful remedy may be divested of all its deleterious properties; that, therefore, it will probably come into general use among us; and they will allow that I have not bestowed too much time on this important subject. I wish the details had been more complete, that my experience had been more extensive, and that I had been better able to satisfy the reader's curiosity and my own.

Some of my readers, who have lately been in the habit of using iodine cautiously, and of watching its effects, may think that I have overcharged the picture of its baneful properties; but I have been an eyewitness of all I have written; and I should extend this treatise much beyond the limits I have assigned to it, did I detail all the cases that have reached me of the mischief it has produced. I am glad, however, to add my testimony to that of Coindet, de Carro, and others, that this medicine may most certainly be deprived of all its hurtful qualities, by using it cautiously and watching its effect. Like all other powerful medicines, when its action is not controlled by the hand of a master, its energies become a source of mischief and ruin, instead of restoring the blessings of health and strength; but when well managed, it is a most useful remedy, and a valuable addition to our materia medica. I have used it myself in a great number of cases, and I have never yet, in my own practice, had occasion to regret the occurrence of any of the violent symptoms I have described. I have more than once discontinued the medicine on finding the pulse become frequent, small, and depressed, on account of watchfulness, flying pains of the joints, tremors, or pain at the stomach; but having early detected these symptoms, they were not allowed to become formidable. Dr. Coindet states, that he has prescribed the medicine to one hundred and fifty patients, and that he has never had occasion to observe any mischief from its use. Dr. Decarro has given it at Vienna to one hundred and twenty patients; Dr. Erlinger, of Zurich, to seventy; and Dr. Formey has prescribed it extensively, in Prussia, with the same favourable results. Dr. Decarro, in his enthusiasm about this new medicine, seems almost to doubt whether accidents have ever occurred from its use, though these accidents have been as public as the day, and the unhappy patients have paid with their lives the inexperience and rashness of their physicians. Thus far I can agree with Decarro, that I have never known or heard of any bad effect from iodine, when it had not been used unadvisedly and injudiciously. It has been used extensively by Hufeland in Germany, who makes no mention of its deleterious properties; and a great number of physicians in London and Paris, and various parts of England and France, have also lately employed it. They have either not met with the accidents I have described, or have prudently concealed them.

Dr. Coindet, however, though he must be acquainted with the sad accidents which have occurred in his native city, has not yet taken any public notice of them. This silence on facts so important seems in some degree to invalidate his testimony.

Having now considered the effects of iodine on the alimentary canal and the nervous system, we are prepared for studying its effect on the absorbent vessels, by which its use in medicine is indicated. This is the most important subject which has yet fallen under my review, and I shall give it as much extension as may be necessary for its perfect discussion. It has been already seen at pages 10 and 12 that the lymphatic system is very powerfully and generally stimulated, so as to occasion a great absorption of all the sebaceous, muscular, and glandular structures of the body; but it will be seen, in the following pages, that the action of iodine may be directed exclusively against tumors, and local disorders, while the healthy structures of the body remain unaffected.

The absorbent system is distributed over every part of the body. In the brain alone the vessels of this class have not, hitherto, been detected and submitted to ocular demonstration by any other anatomist than Mascagni. But physiological and pathological proofs of their existence, equal in force to any anatomical evidence, are not wanting to demonstrate their presence in the central organ of the nervous system. The office which these vessels discharge, in the nutrition of the body and removal of its waste, is most important to its healthy condition; and the influence it exerts, in a state of disease, is not less considerable. From the inactivity or obstruction of the absorbent vessels, a great proportion of the chronic disorders of the body take their rise. Medicines, therefore, which act either directly or indirectly on this system, have always been accounted most valuable articles of the materia medica. Unhappily, they too often deceive us in their operation, and, notwithstanding the united studies of many physicians directed to them, the causes of their failure, as well as the circumstances under which they succeed, still remain a problem. A considerable step towards the solution of this difficulty has, indeed, been lately taken by Dr. Blackall. Much obscurity, however, yet rests upon the subject, and a direct medical agent on the absorbent system, whose effects are speedy, indubitable, and powerful, is a great desideratum in the art of healing.

Such an agent is iodine. Its effects on the absorbent system are incontrovertible. They are as speedy as they are certain, and so powerful are they, that if the medicine be not duly and cautiously managed, we have already seen what havoc may be the result. A few, a very few, cases have occurred to myself, in which the constitution was altogether insensible to its action; I believe a greater number have occurred to others; but I cannot help thinking that such cases have been owing, in many instances, either to some fault in the medicine, or to some inadvertence on the part of the practitioner.

The iodine which is sold in the shops is of very different degrees of purity, which will probably afford an explanation of some of the above anomalies. But still after all possible care has been taken, there will be found a few instances in which it does not appear to possess any power over the absorbent system.

We shall first consider the use of iodine in the treatment of bronchocele, the disease for the cure of which it was introduced into practice. All the physicians who have employed it bear unequivocal testimony to its efficacy. It seldom fails of effecting a complete cure, and when it does, it almost always reduces the swelling very considerably. The promptitude of its action is at times very extraordinary. Decarro states, that one of his patients, thirty-eight years of age, after taking the remedy for seventeen days, had the circumference of his neck reduced from one foot seven inches and a half, to one foot three inches and three-quarters. Dr. Coindet relates a case of a man, fifty years of age, in which this medicine, taken internally, reduced a very large go?tre considerably in size, after six days' treatment only. An old woman, aged sixty-five, who took this medicine under my care for a go?tre, with which she had been affected nearly forty years, had the circumference of her neck reduced from twenty-two inches to eighteen, on the twenty-fifth day. Such rapid diminution in the size of the tumor is not to be always expected. In some cases a whole month, and even more, elapses before any effect is visible. In general, however, the powers of the medicine are manifest at the end of the second week and considerable progress towards cure has been made at the end of a month. I have endeavoured to find out whether there was any thing in the constitution of the different persons under my own observation, or in their state of health, which rendered them more or less apt to be affected by this medicine. I have not been very successful in this inquiry. But I found that in two cases of women afflicted with extensive and very painful varix of the veins of all the extremities, the effect of iodine was produced with great difficulty. This fact seemed to coincide with the result of Mr. Magendie's very interesting experiments on absorption, and I accordingly desired one of the persons, to whom I have just alluded, to lose a little blood from the arm. The effect of the medicine was very much accelerated by this treatment, but a consequence I did not look for was also the result of it, viz. the total and sudden disappearance of the varix, which had commenced during uterine gestation twelve years before. The go?tre succeeded the varix after her delivery. I merely mention the facts of this case, which may suggest useful hints to those who may meet with a case similarly circumstanced. Since its occurrence, whenever the medicine is slow in its operation, provided the vessels be full and plethoric, I desire a little blood to be taken away from the arm, and I almost invariably find the action of the medicine much quickened. I have sometimes, also, thought that the cases, in which blood was taken away, were cured more easily and with less suffering than the others.

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