them; the various phases of degeneration and inflammation; the characters of tumors and the lesions of general diseases, of poisoning and of violent deaths; and finally to describe, briefly, the special lesions of different tissues and organs of the body.

This task has been wonderfully well done, in the book before us. Dr. Prudden is responsible, alone, for the alterations and additions to this edition as Dr. Delafield no longer shares in the preparation of the book.

The scope of the foot notes has been enlarged, causing them to indicate special studies and reviews relating to the theme under consideration.

The chapters on the Blood and Bloodforming Organs and the chapter on Tumors have been rewritten and the section on Malaria revised by Prof. F. C. Wood.

Part First considers General Pathology; Part Second, Special Pathology, and Part Third, The Method of Making Postmortem Examinations and the Methods of Preserving and Examining Pathological Tissues.

Orthopedic Surgery.

By Edward H. Bradford, M. D., Surgeon to the Boston Children's Hospital, etc., and Robert W. Lovett, M. D., Associate Surgeon to the Boston Children's Hospital, etc. New York: Wm. Wood & Co., 1911. $3.50 net.

No two men in the profession are better fitted for the preparation of a book upon this subject than the authors, Drs. Bradford and Lovett.

They have brought to the writing of this book an experience of thirty years in private and clinical work, the latter at the Boston Children's Hospital.

Tuberculosis of the bones takes up the first 114 pages, this pathological condition being perhaps of the most frequent cause of bony deformity in children. No attempt is made to give the avenue of

infection or the nature of the bacillus in these affections.

Fixation, distraction, protection and operative treatment are discussed in the description of local treatment of the individual joints. Frequent illustrations are used in the text of these first pages, as well as throughout the book.

So many appliances have been suggested for the relief of the deformities following joint lesions that a book of this kind which discriminates between them and recommends those which experience has proven most suitable should have a warm reception.

SPECIAL WESTERN NUMBER.

In furthering the plan of producing special issues of the American Journal of Surgery, composed of contributions by surgeons residing within a certain geographical area, yet of international reputation, there will be issued in the early part of 1912 a Special Western Nnmber of this magazine. Subjects and those to contribute: The Operation of Gastroenterostomy, by William J. Mayo, Rochester, Minn.

The Surgery of Tendons, by John B. Murphy, Chicago, Ill.

Operative Treatment for Graves Disease, by George W. Crile, Cleveland, Ohio.

VOLUME 18

Original Contributions

IODINE AS AN ANTISEPTIC.* BY W. O. ROBERTS, M. D.,

LOUISVILLE, KY.

The great attention that the tincture of iodine has attracted, within the past few years, as an antiseptic for sterilizing skin surfaces and accidental wounds; and the fact that the subject has not been brought before this society for discussion, is my reason for introducing it to-night. Soon after the germ theory of inflammation was established, iodine in an aqueous solution became a favorite with many surgeons for sponging and irrigating

purposes.

In 1886 I saw Mr. Bryan use it in a number of operations at his clinics at Guy's Hospital, London. I think the strength of the solution was a teaspoonful of the tincture to a quart of sterile water. He told me that he had been using it for many years, and that he preferred it to all other antiseptic solutions. Nicholas Senn considered iodine "one of the most potent, least harmful and most reliable of the known antiseptics." He used it in an aqueous solution. Iodine 1 part, iodide of potash 1 part and water 100 parts, is known as Senn's solution.

Among the first to use iodine for skin. sterilization was Heusner (Heusner:

Read before the Medico-Chirurgical Society.

NUMBER 8

Centralblatt fur Chirurgie 1906). He dissolved it in benzine 1:1000. Others about that time used the ordinary tincture upon the skin after previously cleansing the field with soap and water, and bathing it with alcohol, bichloride solution, etc. It was not until Grossich's paper (Centralblatt fur Chirurgie, 1908) appeared, however, that the tincture of iodine came so prominently to the front as a skin sterilizer. He pointed out that thorough sterilization could be obtained only when the tincture was applied to a dry surface; that previous washing the surface with soap and water interfered with the penetration of the skin by iodine, and also that the irritating effect of iodine was more marked when applied to a moist surface. The following is a synopsis of his paper: "Grossich had been using iodine in emergency surgery for a year before he commenced its use in all kinds of surgical work. He found that soap and water cleansing of injured fingers and hands was followed by redness and infection, even when the usual antiseptics were applied, and that those treated by iodine applications healed without these complications, or in other words, by primary union. He then began to use the method in all classes of cases with dry shaving, but without further preparation, before applying the tincture of iodine, and always had perfect healing. He then made careful micro

scopic examinations in order to ascertain

the cause of this difference in results. He alluded to the development of the superficial layers of the skin and their elevation and separation from the basal layers. The spaces between these layers are occupied by the various forms of bacteria, fat, sweat, etc. The inter- and intracellular capillaries and lymph spaces all communicate with these layers of epithelium, and it is conclusively shown that iodine penetrates into all these various clefts and openings of the skin. The alcohol of the tincture dissolves the fat, which is always found in the capillary spaces, while the iodine has a special penetrative quality of its own, and forms at chemical combination with the fatty acids. of the skin, which combination is quickly absorbed. The soap and water cleansing is wrong principle, or at least the skin thus prepared is harder to disinfect, because, first, the loose epidermic scales. are made to close the spaces which contain bacteria, and secondly, the spaces are filled with the soap solution, which prevents the entrance of the antiseptic solution. The particles of soap cannot easily be washed away with water, and actually form a protective coating for the germs which are hidden beneath.

"Grossich gives his house patients a bath the day before the operation, dresses them in fresh linen, and applies the iodine just before the operation. He is convinced that iodine gives the best skin sterilization, and absolutely prevents infection from the side of the patient. He gives a final application of iodine before applying the usual dry dressing." (Stone, Trans. Southern Surg. and Gyn. Assn., 1909.) Walther and Tourrine (Bull, et Mem. de la Sodec., Chicago, March 16, 1909) in a paper beautifully illustrated with microphotographs, showing the depth tincture of iodine penetrates the

tissues, prove conclusively the claims made by Grossich's in every particular. They placed sections of skin, that had been painted with iodine, in a solution of nitrate of silver which precipitated the iodide of silver in the tissues. Where the iodine was applied to a dry surface the sterilization was perfect eight minutes. after the iodine had been applied, as shown by microscopical and bacterial examination. But after washing with soap and water the penetration was quite superficial and consequently the sterilization was not so complete. Previous bathing

the surface with ether was followed by deeper penetration.

Grossich uses a 10% tincture (Italian) of iodine. Because of the frequent occurrence of blisters following its application, it has been considered by most surgeons too strong. The U. S. officinal tincture, which was formerly a 5% solution, but is now a 7%, not infrequently causes blisters, especially in patients with an idiosyncrasy. So, many surgeons are now using a 22% solution.

J. W. Bovee (a paper before the American Gyneological Assn., 1911) has proven by recent operations that the U. S. P. tincture diluted one half with 95% grain alcohol is sufficiently strong to produce complete sterilization of the skin on any part of the body, without any undue irritation, and it will "continue sterile indefinitely, or at any rate for thirteen days." Dr. Bovee omits the iodide of potash, which the present U. S. P. tincture contains. The bacteriological investigations were made for Dr. Bovee by Dr. J. S. Neate, microscopist for the Army Medical Museum, who was arranging for an efficient tincture to form a part of the U. S. Army first-aid packages. It is claimed by many surgeeons that iodine acts much better when used in a fat dissolving fluid; that is, it penetrates deeper.

Heusner recommends 1:1000 solution in benzine. This is said to be too weak, but benzine will not dissolve a greater quantity. Many bathe the surface thoroughly with benzine before applying the iodine. Laiscone (La Genecologia Modeina, 1909), by experiments on guinea-pigs, demonstrated that when dissolved in acetone the iodine would penetrate entirely through the skin into the subcutaneous tissue.

Ellice McDonald (Med. Record, April 15, 1911) used 2 parts of iodine to 98 parts of carbon tetrachloride and claims that this mixture combines the advantages of Grossich's tincture of iodine and V. Herff's alcohol-acetone method of skin sterilization.

In a paper before the American Association of Railway Surgeons, Oct. 19, 1910, Dr. P. B. Magnuson, Assistant Chief Surgeon of the Rock Island Lines, said: "In Mercy Hospital (Chicago) we have used nothing but the 10% solution of iodine in the casualty service for the past thirteen months, without the infection of a single scalp wound, and as nearly as I can determine by inquiry among the staff, without any serious infection in more severe injuries. The patients are brought in covered with grease and dirt, and not a move is made towards antisepsis excepting to pour or swab tincture of iodine into the wound and to cover a large area around it with the solution, then a dry dressing is applied." In the free discussion of this paper, there was almost a unanimity of opinion in favor of the iodine method of treating such wounds. There was, however, difference of opinion as to the strength of the solution.

Post and Nicoll (Journal of the American Med. Association, Nov. 5, 1910) tested the germicidal qualities of numerous antiseptics in use, and found that an

aqueous solution of iodine 1:400, destroyed all forms of micro-organisms in one minute, and that a solution of bichloride of mercury 1:2000, failed to kill the streptococci in thirty minutes. So "what is the use of irritating one's hands by plunging them into a 1:2000 bichloride. solution for one minute? The naive and blissful belief of some operators in the germicidal value of bichloride of mercury for skin surfaces would be amusing were it not pathetic." (Ellice McDonald.)

* *

a

A. C. Hanson (Railway Surgical Journal, Oct., 1911) wrote a number of prominent surgeons as to the various antiseptics used by them in the treatment of wounds and received the following replies: Wm. Mayo wrote: "* general antiseptic, a sort of good-for-allpurposes, would be the plain tincture of iodine." J. B. Murphy: "Our emergency patients are treated by saturating the wound and skin with pure tincture of iodine. If any dirt is ground into the skin or tendons, it is not rubbed out or mopped out; there is no water used in the preparation whatever. The tissues into which the dirt is ground are cut away by means of forceps and scissors. In our operative work we prepare, the night previous, the field of the operation by cleansing with soap and water, alcohol, ether, and bichloride. The next morning, immediately before the operation, paint the skin with iodine." Dr. A. J. Oschner : "For many months we have used strong tincture of iodine in all wounds due to injury, and now wash the surface with benzine, then saturate the wounded surface thoroughly with the iodine." Major Frank Woodbury, U. S. A., says tincture of iodine is the ideal military and railroad surgeons' antiseptic, and that as good results can be obtained with it in a hut as with the most aseptic or antiseptic conditions in a marble pavilion (New

York Med. Journal). Some writers have alluded to iodine-peritonitis, that is peritonitis resulting from the use of iodine. painted on the abdomen prior to a laparotomy. I wrote to a number of surgeons for their opinion on this point and have received only three replies so far:

NEW YORK CITY, Nov. 6, 1911. DEAR DR. ROBERTS: It is a pleasure to answer your questions.

First. I do not confine the use of iodine to emergency cases.

Second. Two preparations are used chiefly: the 2% solution of iodine in carbon tetrachloride, as advanced by Dr. Ellice McDonald, is one of the best; a 2% solution in benzine is next in favor.

Third. There is distinctly danger to the peritoneum from iodine used in the officinal tincture. I began using this preparation when it first was described by Cannaday some years in advance of the famous paper of Grossich. Sometimes now, when operating at various hospitals to which I am called for the first time, some assistant will have officinal tincture of iodine all over the field for operation. before I notice it. This strong preparation of iodine not only may blister the skin, but I have noticed many times a marked local peritonitis, due without question to iodine carried to the peritoneum from the skin, in such a case. There is no question about it. I have noted the effect too distinctly and promptly to have any doubt. If some assistant gets the skin covered with a strong iodine preparation before I can stop it, as much as possible of the iodine is removed with alcohol before an incision to the skin is made.

Yours truly,

ROBERT T. MORRIS. November 6, 1911. DEAR DR. ROBERTS: Answering your

letter I beg to say in answer to your questions that I do use iodine as routine in my operative work. The night before operation the abdomen is cleaned in the ordinary manner with water, ether and bichloride; on the day of operation, and two hours before operation, we use a 2% solution of iodine in either benzine or alcohol; and on the operating table, a 5% and 7% tincture of iodine. In answer to your third question I would say, no; at any rate I have never known any danger to result.

With kind regards and best wishes, believe me,

Very truly yours,

JOHN B. DEAVER.

November 14, 1911.

DEAR DR. ROBERTS: In reply to your letter of the other day, I would say that I am not using iodine at all. I have no special objection to using it, except that I am perfectly satisfied with my method, which has served me well.

Yours very sincerely,

MAURICE H. RICHARDSON.

DISCUSSION.

DR. L. S. MCMURTRY: I have cer

tainly enjoyed Dr. Robert's excellent paper; he has treated the subject very thoroughly.

It occurs to me that the use of such agents as form the subject of this paper is, theoretically, a step backward; it is the substitution again of antisepsis which has been largely replaced by asepsis. Of course, no one can gainsay the value of tincture of iodine as an antiseptic agent in emergency surgery, especially in cases. such as Dr. Roberts described, where a man has sustained an accident, and is brought in with a wound filled with dirt