Since Finsen announced his famous “Light” treatment for lupus some eight years ago, there has been much activity on the part of medical men and manufacturers to produce a cheaper less complicated instrument, which would accomplish the almost perfect results of Finsen more quickly, with less supervision, and at less expense than the original Finsen apparatus. The result today is, that, following the example of the Europeans, the Americans have produced “Finsen lamps of greatest efficiency” galore, until almost every up-to-date office has a so-called “Finsen outfit.” Some of these lamps have more or less merit, and are constructed on scientific principles so that they are valuable accessories for the more superficial treatments; while others have little to recommend them. The result of it all is that there is much misunderstanding as to the true nature of the genuine Finsen light, and as to what it will accomplish. Reports of treatment given with apparatus of other construction than the original Finsen, should not be given without designating the name of the lamp used, for all, so far as the author is aware, lack the scientific features in their construction, which are necessary in order to secure the most marvellous cures which are noted in the Finsen Institute at Copenhagen.
It is frequently asserted that the efficient agent of the Finsen light is the ultra-violet ray, the equally important blue and violet rays appearing to be left out of consideration in many of the discussions noted in the literature, as well as in the construction of the various lamps for the purpose of improving upon or imitating the Finsen.
This misconception is probably accounted for from the fact that Finsen, in his earlier work, believed that the blue and violet rays alone were the bactericidal rays, “While,” he says, 1 in his first communication on the subject, “there was some divergence of opinion respecting the ultra-violet rays.” But, later, he confirmed, 2 the researches of Widmark and proved that the ultra-violet rays were the most bactericidal, and that the inflammatory effects of light were due to the “rays of greatest refrangibility”; and, that of these, the blue and violet were sufficient alone to produce such an action, “though,” he adds, 3 “their action was much weaker when they were used alone, than when their influence was enhanced by the addition of the ultra-violet rays.” And this is the secret of the Finsen treatment. Consequently he constructed his apparatus with the largest quartz-crystal lenses that could be procured, consistent with expense, and with a light-source (the carbon-arc), so arranged with regard to tension and amount of current and composition of carbon, as he found by most careful experimentation, to produce a light the richest possible in blue, violet and ultra-violet rays, consistent with elimination of heat, in order to concentrate upon the skin the largest practical number of the combined actinic rays.
No one worked harder to produce a cheaper and more practical apparatus than did Finsen himself and his assistants. The result was the invention in the Finsen Laboratory of the Bang Lamp, an instrument with water-cooled iron-electrodes, whose light was very rich in ultra-violet rays, a type of lamp which has been modified in various ways by Kjeldsen, Reiniger, and Andre and Broca-Chatin (“Dermo-Lampe”) and others. Soon after there appeared the Lortet-Genoud lamp – an instrument with a carbon-arc as a light-source, which is placed much nearer the patient than is that of the Finsen apparatus, and is not concentrated, the quartz-crystals, too, being very much smaller than in the Finsen. The London Lamp of Dr. Sequeira is a modification of this, and it is in quite common use. Perhaps next to the Finsen apparatus this is the most effectual of all. In this country there are several lamps of this type manufactured. Another type is the high-tension condenser-spark lamp introduced by Görl. This lamp, like the carbon-arc, is rich in ultraviolet rays, but not in the blue and violet. Of course, there is no concentration. Piffard, 4 of New York, modified the Görl Lamp by substituting three spark-gaps. Recently Piffard 5 has placed another phototherapeutic lamp on the market, which has iron electrodes in a very small compass, is very cheap and convenient, but of course, very superficial in its action.
After much experimentation with these various types of lamps, Finsen 6 says, “these lamps seemed in the beginning to promise well, but have not answered to our expectations. They have, however, taught us that closer investigation is needed as to the power of the different kinds of rays to penetrate through heat, and that it will be of little use to work further on new lamps until this question is cleared up. The lamps we now use are constructed for the purpose of lighting, and not for the purpose of producing inflammation and killing bacteria.”
Laredde and Pautrier, 7 after much clinical and laboratory experience with many of the later lamps have concluded that the original type of lamp as devised by Finsen gives the most satisfactory results, its power of pentration being greater; and, that while they have had fairly good results from the Lortet-Genoud lamp, they have found that the twenty-minute exposure advised as sufficient with this lamp, was not long enough, but, that better results were secured by exposing for one hour, as advised as necessary for treatment with the original Finsen apparatus. The reason for this will be explained later.
Dr. Bie 8 has shown that the blue and violet rays can penetrate deeply into the skin, but only when it has been made bloodless; and the ultra-violet rays can, under no circumstances penetrate deeper than the superficial layer of the skin, but they give rise to dilatation of the bloodvessels, which may persist for months.
Jansens found that the rays from the soft iron, water-cooled electrodes, such as characterize the Bang type of lamp, were very rich in ultra-violet rays with wave length of about 322 micro-millimeters; that they were strongly inflammatory, but also strongly absorbable, so that a thin layer of agar or gelatin protects the bacteria in perceptible degree from the action of these rays. When a plate-culture of B. prodigiosus in agar was exposed to the rays from such a lamp, he found that the time necessary to kill the bacteria increased 64 times; while, with the intervention of a skin-layer 1/2 mm thick between such a light and the bacteria, there was very slight action on the germs after an hour’s exposure. Substituting the Finsen apparatus for the iron-lamp, other conditions being the same, the bacteria were killed after 9 or 10 minutes’ exposure. The iron-electrode lamp required 2 to 5 minutes to blacken chloride of silver paper placed behind the dehaematized ear of a rabbit; but the Finsen apparatus required less than a second. With both ears in contact it was not possible for the iron-electrode lamp to blacken the paper in 5 minutes, while the Finsen did it in less than 6 to 10 seconds. Thus is demonstrated the much greater penetrating power of the great Finsen light.
But, in spite of this test, it has been frequently asserted that these iron-electrode lamps were much more effectual than the Finsen requiring only 15 or 20 minutes to accomplish what the Finsen light requires an hour for. But these assertions cannot be proven by either clinical or laboratory experience. Prof. Kromayer 10 is one who has made this assertion in favor of the iron-electrode lamp, and Gunni Busck 11 has made further experiments which show the absurdity of such statements. He allowed the rays from a Finsen, Bang, and Dermo-lamp (the two latter being iron-electrode lamps) to fall on the anterior surface of his forearm where the skin is particularly thin, until the minimal (just visible) skin-reaction would be produced, and the following were the results:
Finsen Light, 8 seconds; Bang Lamp, 10 seconds; Dermo-lamp, 40 seconds; which show that the light from the Dermo-lamp is 5 times weaker than that from the Finsen. When, however, he exposed the palm of the hand, where the skin is much thicker, the Dermo-lamp failed a number of times to produce a reaction after 30 minutes’ exposure, which the writer knows from experience can be accomplished after 20 or 25 minutes with the Finsen lamp.
Kromayer sought to improve on the Dermo-lamp by using 45 amperes of current instead of 5 amperes, as in the original, and by filtering the rays through methylene-blue solution, but Busc found that the light from this improved lamp required three minutes to blacken chloride of silver paper, placed behind the bloodless ear of a rabbit, while Finsen Light required only 1 to 4 seconds. So Busc rightly concludes, that, since the chloride of silver paper is only in slight degree affected by the less refrangible rays, the above experiment shows that the Kromayer light contains 60 times less blue-violet rays than the Finsen light, and that Kromayer obviously underestimates the capacity for the carbon arc-light to produce these rays.
Similar results from experiments with other sources of light might be quoted, but these will suffice to show the penetration of the Finsen Light.
As Busc remarks, “it is the use of these so-called improvements on the Finsen light in such cases as lupus, epithelioma, and the deeper seated skin lesions that brings disrepute on the Finsen treatment.”
The writer has quoted these experiments because he desires in justice and fairness to the Finsen treatment, to protest against the common practice of denominating as a Finsen lamp any kind of a photo-therapeutic lamp, the construction of which may involve only a few or none of the principles enunciated by Finsen.
The technique of the treatment is most difficult. When properly carried out, we note immediately following the treatment a circular redness of the skin, and the patient may be conscious of a slight burning, or have no particular sensation in the part. After a variable period of 18 to 24 hours a circular vesiculation, more or less marked about the red area is apparent. This reaction, in some cases however, is delayed to 48 hours after treatment. The part now feels sore with a sensation the same as in a sun-burn. The vesiculation increases somewhat for a few hours, and then the vesicle dries and crusts over, while the cuticle looks brown and pigmented. After about a week this peels off, and leaves a red or pink skin beneath. Many times the peeling is delayed for 10 days or two weeks, depending somewhat upon the reaction. Some patients react more strongly than others. For instance one of the writer’s patients with a small epithelioma of the nose, with an ulcer about the size of a split pea in the centre; always had very severe reactions. The treatments themselves, which are usually painless, seemed to cause much burning due to the pressure with the compressor. The day following each of the first three treatments the nose and half the face swelled, the eye was closed, burning was intense and headache so severe that the patient was obliged to take to her bed for several days. By the end of two weeks the reaction entirely subsided and the lesion was much improved. This, however, was a most unusual case, the pain during the reaction being comparatively insignificant.
Burns from the Finsen treatment are rare and unnecessary, being invariably due to carelessness on the part of the operator or the patient. They are unnecessary, because like any other burn, except an X-ray or radium “burn,” they give the pain of a burn at the time, and this comes on so gradually, that the patient has time before damage is done to inform the operator, who will find that, from one cause or another, the cone of light from the lamp does not fall simultaneously at right angles on all parts being treated, and this can easily be corrected. The burn, of course, is an ordinary one which heals like any superficial burn, the only permanent damage being a scar.
The length of treatments varies from 15 minutes to 11/4 hours. Red birth-marks require but 15 or 20 minutes, as does also alopecia areata, and some eczemas, where there is not much infiltration. Most cases of chronic eczemas, however, are cured in or two half-hour exposures. Psoriasis and Lichen planus usually require one hour of treatment, as does also lupus vulgaris and epithelioma, though the two latter sometimes need a quarter of an hour extra. In some cases of lupus erythematosus the treatment has been given by the author but half an hour, though usually one hour is given by Finsen. Some of the cases treated just half an hour seemed to do better than those treated a full hour, the longer treatment apparently aggravating.
The question of length of exposure is an interesting one, and the great length of time necessary for the Finsen treatment has been a serious drawback to its use in this country. We Americans have not enough patience. With us the treatment must be carried out in a hurry.
Naturally the question is asked, if the Finsen light will destroy bacteria in a few minutes after passing through the skin, why give the treatment for an hour or more? Experience has taught Finsen that this amount of time is required in lupus in order to secure good results. But why is that the experience?
There has been much discussion of the question pro and con as to whether the curative effects of the light in lupus are due to the action of the actinic rays on the bacteria or to the inflammatory reaction set up in the skin. Freund 12 is of opinion that the destruction of the bacteria is of minor importance, the real curative action being the result of the inflammatory process, a phagocytosis, and he quotes Bang, Müller, Glebowsky, Serapin and Sack, who sustain him in this view. That the cells of lupus are absorbed as a result of the light treatment has been amply demonstrated by Schmidt and Marcuse 13 who made microscopical sections of the skin and lupus areas at variable periods after treatment. Sixteen to 24 hours after the Finsen treatment, there was engorgement of the bloodvessels, a wandering of the polynuclear leucocytes between the epithelial cells, a vesicle beneath the horny layer filled with leucocytes, oedema and degenerative changes of the upper layers of the epidermis, and of the epithelioid cells of the lupus nodes. The changes in the epithelia affected only the corneal and granular layers, the papillary layer not being injured, which latter fact accounts for the favorable cosmetic results.
Five days after the last of three treatments of an hour each, five to seven days apart, the blood vessels were observed to be moderately dilated, and the epidermis to have been almost regenerated, but a few scattered groups of mononuclear round cells and giant cells deep in the skin demonstrated the great resistance of these cells against the action of light. The small mononuclear round cells appear to be the most resistent of all the cells of the lupus node, and there is very good evidence that retrograde changes in these cells go on very gradually for several months after the treatment, while the epithelioid cells of the superficial nodes are quickly destroyed after one exposure to the light.
Therefore we see the necessity for the long exposures. The deeper the disease cells, the weaker is the action of the light, and those cells which we find in the deeper parts of the lesions are more resistent to the light than the superficial cells, hence they must have a longer exposure. The weaker light-sources, composed largely of the rays of shorter wave-length, would not affect these deeper-lying and more resistent cells at all.
The cause of the absorption of the cell is probably a direct chemical one, some of the albumins being changed, so that further development in the life-cycle of the cell is interfered with, and absorption takes place.
Dreyer 14 of Copenhagen has recently discovered that he can sensitize bacteria to the action of the yellow and green rays, which have been shown to be inert. Inasmuch as these rays are of so much longer wave-length than the so-called chemical rays, they penetrate much deeper, even clear through the hand. The writer has tried Dreyer’s plan, which consists in the injection of erythrosin 1 to 1000 solution in normal saline solution two to four hours previous to treatment, but was disappointed in the results, though there was apparently much improvement at first. It is possible the technique was not properly observed. A very severe inflammatory reaction appeared after such treatment in a case of cancer of the nose and cheek where the infiltration was several times too thick for the penetration of the blue-violet rays of the Finsen light. But the tumor after two or three such treatments began to grow much faster than usual, so that the light treatment had to be discontinued. In some cases of eczema of the hand where the eczematous parts were soaked in this solution for ten or twelve hours previous to treatment (no injection being given) the treatment was only given twenty minutes with very satisfactory results, eczematous patches of twenty years standing disappearing after two such treatments. In psoriasis twenty or thirty minute exposures were not sufficient after applying the erythrosin in this manner, but two or three treatments of an hour each accomplished an apparent cure; though, with its tendency to relapse, the cure cannot yet be pronounced permanent.
When it is considered that cases which do not yield readily to other forms of treatment, and have perhaps been under treatment for many years, can be cured after a few hours exposure to the Finsen light, this form of treatment does not appear to be too long or too expensive. The action of the light in selected cases is so certain that, if it were not for injuring the precious feelings of medical ethics, one could guarantee absolutely a permanent cure in a few weeks to a few months. And what is this time compared with the time previously spent in a vain endeavor to secure relief 1. And this can be done without any danger to the patient such as is the case with the x-ray treatment.
As to a choice between the x-ray and the Finsen light, it is the writer’s experience that each form of treatment has its indications, though we are not able at this time to definitely outline the same. Lupus is undoubtedly better controlled by the Finsen light than by the x-ray, and the Finsen treatment does not consume much or any more time in these cases than does the x-ray. On the other hand epitheliomata and rodents appear to be more responsive to the x-ray, though about 50% of selected superficial cases are cured 15 by the Finsen light. Many of the cases however are too deep to be affected by the Finsen light. The writer has seen chronic eczemas clear up for a short time under the action of the x-ray, only to reappear in a very short time. These cases were then treated with the Finsen light with apparently permanent results, though the time intervening (10 months) is yet too short to say positively.
Wine-colored birth-marks are speedily and permanently removed by the Finsen light, and the treatment of three of these cases has given the writer much satisfaction, not to mention the gratitude and happiness of his patients. They are treated 15 to 20 minutes with the light, a spot about the size of a quarter being treated in this time. The reaction is many times slower in appearing than in other cases, not being present sometimes until 48 hours after treatment. Then the characteristic vesiculation about the border of the treated spot appears, while the centre becomes brown. After a few days the skin peels off and leaves an area exposed which is several shades lighter than the original birth-mark. This can now be treated again in two weeks, and an additional blanching takes place. If, however, it is not treated again for two or three months it will be noticed that the spot continues to grow lighter for a considerable period. After a few treatments at intervals of a few weeks or months the redness entirely disappears.
In a case of xanthoma, where there were three growths – one on the lower right lid, and one on each of the upper and lower left lids – one 50-minute treatment was sufficient to remove one of them, while another had two treatments of an hour each, and the third on the upper lid which was more difficult to treat, responded after three treatments of an hour each.
A case of lichen planus of 16 years standing on the back of the neck of a young woman, was cured after 4 treatments of an average of 10 hours each, an hour being spent on each spot. Of course each treatment was distributed over three or four days. This case had resisted all kinds of treatment for a number of years.
The light treatment was tried on syphilitic gummata of the thigh which had resisted antisyphilitic treatment for three years. Broken down gummata with painful ulceration healed kindly when their undermined sloughing borders were treated by the light, dressed with a mineral earth containing much mica, oxide of iron, and silica and supported by a protective dressing of zinc-gelatin and lint. Gummata which were not far advanced were almost completely absorbed when the ulcers were healed and treatment discontinued. About three months later however the patient returned stating that the gummata had been increasing in size and giving some pain. The light treatment was given again with the result that on the third day of the reaction, the corneal layer was noticed to be black. This had also been noticed in the former treatments for a period of three or four weeks after treatment, but it gradually cleared up. The second time, however, it was evident that the gummata would break down for they were pretty soft, and the gangrenous appearance, at first superficial, gradually grew deeper until at the end of a week it had broken down completely. The resulting ulcer, however, unlike her former experiences without light-treatment, soon showed a healthy base and healed kindly in about four weeks. In addition to this treatment the patient took Burnham’s soluble iodine from the beginning.
Four cases of rosacea have cleared up under the Finsen treatment. Two of these cases might be dignified with the name of rhinophym, so great was the hypertrophy of the nose. They have averaged treatment over the entire area five times, an hour to a spot. Shorter treatments were tried, but were not very effectual.
After a year’s experience with the Finsen light, and several weeks’ experience in the Finsen Institute in Copenhagen, in the London Hospital with Sequeira and in Berlin with Lesser and Lassar, the writer believes that in superficial skin diseases which are suitable for the Finsen treatment there is no more effective and speedily curative agent known to the medical profession, and it is surprising that it has not been more generally introduced into this country. No doubt the original price of the apparatus, together with the cost of maintenance, as well as the long treatments necessary, have caused Americans to go slowly in the matter of installing. But it is certainly well adapted to institutional work, and the expense feature is more imaginary than real, for it is the author’s candid opinion that the treatment saves money in the end for the patient, by being so much more certain than any other form of treatment known, and curative where any other treatment fails utterly.
1. Finsen. Uber die Anwendung von concentrirten chemischen Lichstrahlen in der Medicin. Leipsic, 1899. P. 6.
2. Finsen. Om Aevendelse i Medicin af concentrerede kemiske Lystraaler. (Meddelelser fra Finsen’s Mediciniske Lysinstitut. May, 1902.
3. Bie. Phototherapy after Finsen’s Methods. International Clinics. Vol. 111, Eleventh Series.
4. Piffard, H. G. Radio-Praxis. Med. Rec., Mar. 7, 1903.
5. Piffard, H. G. A new and simple photo-therapeutic Lamp Medical Record, Jan. 23, 1904.
6. See pages 46 and 47, No. 1.
7. Lareede et Pautrier. Phototherapie et Photogiologie. Paris, 1903.
Wiener klinischen Rundschau, No. 39, p. 723.
9. Jansen. Die Dermo-lampe. Wiener klinschen Rundschau, 1902. No. 49.
10. Kromayer Dermatologische Zeitschrift, Bd. X, Heft 1.
11. Busck. Eisenbogenlicht contra konzentriertes Kohlenbogenlicht. Dermatologische Zeitschrift, Bd. X, Heft 2.
12. Freund. Grundriss der gesammten Radiotherapie. Wien, 1903.
13. Schmidt and Marcuse. Uber die histologischen Veränderungen lupöser Haut nach Finsen Bestrahlung. Archiv. f. Dermatologie u. Syphilis. March, 1903, Bd. lxiv, Heft 3.
14. Neiser and Halberstaedter. Mitteilungen über Lichtbehandlung nach Dreyer. Deutsche med. Wochenschrift, Bd. xxx, No. 8.