Journal of Medicine and Surgery

A JOURNAL PUBLISHED MONTHLY IN THE INTEREST OF

MEDICINE AND SURGERY

VOL. XVII.

TORONTO, JANUARY, 1905.

NO. I.

Original Contributions.

SOME OBSERVATIONS UPON THE TREATMENT OF LUPUS VULGARIS BY PHOTOTHERAPY, RADIOTHERAPY

AND OTHERWISE.*

BY CHARLES R. DICKSON, M.D., TORONTO,
Electro-therapist to Toronto General Hospital, Hospital for Sick Children, St. Michael's Hospital,

Ex-President of the American Electro-Therapeutic Association and Delegate
of the Association to the International Electrical Congress,

St. Louis, Mo., U.S.A., 1901,

on

UNTIL a comparatively recent period the treatment of lupus vulgaris had not been attended with brilliant results, and it remained for electro-therapy, as

so many other fields of conquest, to point the way to a more hopeful outcome.

This brief paper will not deal with the varied procedures of the past, dignified by the name of treatment, nor yet with all the minute and interesting details of modern scientific technique in such happy contrast with former methods. No striking, novel, original theories will be advanced, but merely a few unpretentious observations, particularly with regard to cases of long standing and unusual obstinacy, as a contribution to the literature of a subject which is deservedly attracting much attention at the present time.

In the treatment of lupus the X-rays scored their first therapeutic triumph, and a most notable one it was. To Finsen is due the credit for compelling the medical profession to recognize the therapeutic efficacy of light in affections of the skin, and this led to the employment of X-rays in the treatment of lupus, the result

being that to-day phototherapy and radiotherapy are admittedly the most potent means at our disposal for combating and conquering a most distressing condition.

Each method has its advocates. In America, radiotherapy has claimed the allegiance of the greater number of investigators, probably due to the fact that nowhere has the static machine reached such perfection of development and use as hère, and nowhere has more enthusiastic admirers, and for the possessor of such a machine the necessary X-ray apparatus involves but comparatively slight additional outlay, while the Finsen light is an expensive luxury, occupying much space and demanding more valuable time than the average practitioner can afford to give it.

Many very ingenious devices have been resorted to in the endeavor to overcome the difficulties which militate so seriously against the popularity of phototherapy. A form of apparatus which I have found of much service in many cases is a condenser spark lamp, with iron electrodes, known as “ The Ultra." It is used with the alternating current drawn from an ordinary incandescent lamp socket. The diminutive arc of this lamp emits comparatively few light rays, but is very rich in violet and ultraviolet rays, as may readily be demonstrated. Being richer in the ultra-violet rays than the Finsen light, it is more powerfully and more rapidly bactericidal, and thus the time of exposure is materially lessened, so that from three to ten minutes only is required, instead of the half-hour, hour or more of the Finsen lamp.

While the ultra-violet rays emitted by the iron electrode arc are of shorter wave length, more refrangible, and not so penetrating as the rays of greater wave length—the longer ultra-violet, violet and blue of the large Finsen lamps-yet they have a wide field of usefulness in lupus, and my remarks upon phototherapy will refer to this branch of the subject alone, demonstrating some of its possibilities.

The treatment of lupus vulgaris in its more aggravated forms is far from a simple process; many considerations are involved and much of the success will depend upon the skill, resourcefulness and patience of the operator, not to mention the faith and perseverance of the patient. Fixed rules cannot be laid down, and yet there are certain preliminaries and adjuvants to treatment, attention to which may be of very material assistance, and these apply to both photo and radiotherapy.

The production of artificial fluorescence of the tissues by administering some fluorescing substance before raying, as elaborated by Morton, is an undoubted advantage. From five to ten grains of bisulphate of quinine may be given one hour before each raying for this purpose. Many other substances may be similarly employed—fluorescin and others..

In very obstinate cases the internal administration of creosote in a form which can be tolerated and readily assimilated, may prove of great value in hastening a cure, and attention should be paid to the general condition of the patient, if necessary.

The diseased tissues should be subjected to as little irritation as possible by manipulation in removing crusts or otherwise, and should also be kept as quiescent as possible in the intervals between treatment in order that extension of the disease may not be favored. If crusts or scales are present they should be removed before treatment if possible, and the parts cleansed. For this purpose, glycerin, to which has been added 25 per cent. of oil of eucalyptus, may be applied, but should it not soon cause loosening of the crusts further attempts at removal should be desisted from for the present and raying proceeded with, allowing the eucalyptus-glycerin to remain on. If the crusts are still adherent at the conclusion of the treatment, they should be kept covered with white vaselin until the succeeding treatment, when they will probably be found softened sufficiently to be removable by forceps or absorbent cotton.

The patient should avoid the use of water or of aqueous solutions for cleansing affected areas if the skin is broken; the parts should be wiped off with vaselin instead, and kept as dry and as clean as possible.

The eucalyptus-glycerin, varying the strength to individual needs, if necessary, may with advantage be applied to ulcerated or broken surfaces and a border of surrounding sound tissues before each raying in inveterate cases. It is quite transparent to ultraviolet and X-rays. In cases where the edges of an ulcer are healing very slowly, but the disease is not deeply seåted, the application of a very thin layer of vaselin to the edges before raying has seemed to accelerate healthy granulation, and as white vaselin fluoresces a brilliant violet under the ultra-violet rays, while ordinary vaselin fluoresces a greenish blue, and to a much less degree, and, moreover, being of a yellow color, absorbs the greater portion of the rays, the former is preferable. Creosote, oil of cloves and oil of cinnamon are opaque to the rays; oil of wintergreen fluoresces blue.

Rays of short wave length are absorbed and neutralized by those of greater length, and the greater the disparity the greater the amount of absorption; hence the short ultra-violet rays are thus affected to the greatest degree by those at the opposite end of the spectrum, the long red orange and yellow. For this reason the removal of crusts before phototherapy is employed is especially necessary, for the color of the crusts, reddish or yellow, will not permit the action of the ultra-violet rays upon the parts beneath.

Blood on the surface or circulating in the capillary vessels has the same effect to a greater degree, and to counteract this effect the surface should be cleaned and adrenalin chloride applied to constrict the capillary vessels and drive the blood out of them, thus blanching the tissues, repeating the application as often as necessary during the sitting. The adrenalin may conveniently be added to the glycerin and applied before arranging the apparatus to be used; it will thus be afforded the few minutes necessary to its complete action before beginning operations, and raying should not commence until the parts are well blanched. It is rarely necessary to employ the adrenalin full strength (1-1,000), in fact weaker solutions may be more readily absorbed. This blanching of tissues and removal of crusts is also of benefit in radiotherapy.

In phototherapy a lens of rock crystal is sometimes employed to press upon the parts to make them anemic, and pieces of ice have also been used for the same purpose, but with the ultra-violet rays, which act so powerfully upon the surface, pressure is to be avoided as far as possible, as causing unnecessary irritation, and more reliance is to be placed in adrenalin. Rock crystal and ice are transparent to the ultra-violet as to the X-rays, while glass is opaque to both, a fact which is sometimes made use of.

If practicable, a margin of sound tissue about one-quarter of an inch in width surrounding the diseased areas should be left exposed to the rays, all other sound tissue in their range should be shielded; in the case of X-rays, thin sheet lead, or the tinned lead composition known as “X-ray metal,” may be used, stellate apertures being cut to correspond with the areas to be rayed, and the points turned back. For the ultra-violet rays the metal is also applicable; oiled muslin is likewise convenient, offering sufficient protection to sound tissue, the rays being absorbed by the vellow muslin.

The eyes of both operator and patient must especially be protected when exposed to either ultra-violet or X-rays. An exposure of a few seconds to the direct action of ultra-violet rays will provoke a very smart conjunctivitis or worse, and it must not be forgotten, also, that these rays are readily reflected by metal or even the skin itself. Large goggles afford a convenient protection, glass being impervious to both varieties of ray, but in the case of the ultra-violet it is safer to protect the patient's eyes with oiled muslin closely fitted to guard against reflected rays.

Where the skin is broken, ulcerated or crusted over, the affected areas and surrounding tissues should be kept in as clean and healthy condition as possible. Immediately after treatment the parts should be cleaned off with vaselin and a very thin layer of some emollient ointment spread upon fine ganze (or, better still, on sterilized linen as being less irritating and more readily removable): this being applied to the crusted or ulcerated patches alone,