NEWTON CENTRE, MASS.
I have selected as the subject of this paper the treatment of a class of cases which, while to the X-ray therapist it presents no particular novelty, has been carried out with some departures from conventional methods heretofore adopted by a large proportion of operators so far as the published literature on this topic would indicate.
The principal variation in method has been in the routine employment of a tube of high vacuum in all cases, for which in the beginning of my work at least, there was no precedent, the weight of authority being in favor of the low vacuum tube and the production of a “mild dermatitis.”
I cannot claim the departure from routine methods as a brilliant inspiration, but rather as having come about through an accidental combination of circumstances.
Some four years ago as an experimental side-issue to general practice I added to my office equipment a small static machine and a single X-ray tube of the non-adjustable variety. The larger part of the work done being in the line of plates for diagnostic purposes, it was desirable that my sole possession in the tube line be in a condition favorable to that class of work. Secondly, my first essay into the field of therapeutic work was in the treatment of a case of recurrent carcinoma of the breast in which I happened upon one of the few patients whom I have found to be unduly sensitive to the X-ray. In this case the second treatment, given with a low tube, was followed by such a violent reaction as manifested by elevated temperature and a general erythema of the trunk, not only of the portion rayed but of the back and sides as well, that I acquired perhaps an undue respect for the mighty force which I had liberated. These circumstances together with the desire of avoiding the much dreaded burn were the determining factors which led to the routine use of the high tube, but as the work progressed it was noticable that the results were as rapidly obtained as in reported cases of a similar nature wherein use had been made of the low tube and the production of an artificial dermatitis. Latterly the use of the high tube has been adopted as a matter of deliberate choice and results have been sufficiently prompt and gratifying to warrant a continuation of a method whereby it is possible to assure the patient that there is little or no danger of producing the X-ray burn, a bugbear that is present in the minds of a surprisingly large proportion of persons presenting themselves for treatment, due no doubt to an injudicious and sensational secular press. Indeed the majority of general practitioners are not free from the association of the use of the X-ray with a degree of danger to the patient far in excess of that which presents itself to the mind of one who is familiar with this class of work.
The first application of the ray to abnormal skin conditions was in the case of an eczema occuring in one of my nurses. There were present on the elbows and the extensor aspect of either forearm a number of dry scaly patches, varying in size from that of a ten-cent piece to that of a silver dollar. These had been present for a number of years dating back to her school days, at which time they made their first appearance, resulting apparently from friction and pressure from the school desk. During a period of two weeks three applications were made to each arm of fifteen minutes’ duration and with the anode one foot from the skin. The result was the entire disappearance of the roughened condition, the only evidence of former disturbance being the persistence for some weeks more of a dusky discoloration upon the sites of the former lesions, and even this in time entirely disappeared leaving an apparently normal integument. This relief continued for some two years or more but has since recurred following marriage and parturition. A resumption of treatment had been contemplated but household cares together with the confinement incident to the management of a small infant have prevented up to the present. While the results in this case were not absolutely permanent the case seems to be worth reporting from the rapidity with which it yielded to treatment as it had not done in the past to much more extended efforts in the way of both local and constitutional treatment.
Later on the small apparatus was replaced by a ten plate machine and a more extended equipment of tubes of the adjustable variety and with this more powerful apparatus the cases following have been treated during the past year, and while the number is not large, it represents all cases treated during that time which have not heretofore been reported and which can come strictly under the classification of skin diseases. This is simply mentioned in passing that it may not be presumed that a selection of favorable cases has been made, the desire of this paper being to present an absolutely accurate summary of work done, that the true value of this method of treatment may be shown.
Case 2. This patient was a domestic who had been suffering for a number of years from an eczema of the palms and palmar surface of the fingers. When she came under my care there were extensive lesions upon the palms of each hand, particularly about the roots of the fingers and extending between the fingers with numerous fissures bleeding at times and extremely painful. During the years in which she had been afflicted various methods of relief had been tried with little or no success although at one time by entirely suspending her work for three months or more and giving her whole attention to her hands she did succeed in getting them entirely healed, but immediately she resumed her work the lesions again appeared in no less severe form. She was again prepared to give up work temporarily during treatment but it seemed desirable that this should not be done, the real value of the treatment being in overcoming existing conditions with no change from ordinary occupation. Furthermore she was advised in no way to favor the hands but to allow exposure to the chemical effects of laundry soap and similar irritants entering into the necessary articles of ordinary domestic employment. This course was pursued, treatments being given for fifteen minutes at one foot three times a week. The first few treatments relieved the painful condition and at the end of the second week there was an entire healing of fissures. Later they recurred in a slight degree to yield still more readily to treatment and finally at the end of three months, eighteen treatments having been given in all, the case was discharged as apparently cured and I believe the result to have been permanent as she gave assurance that should there be a recurrence she would again report for treatment and at the end of some nine months she had not yet so reported.
Case 3. This case was one of psoriasis occurring in a young married woman and which had been present for three or four weeks. There were isolated patches upon the upper portion of the chest, also upon the back and posterior aspect of the thighs. The annoyance from itching was extreme. The outer clothing was removed substituting a cotton night robe and through this treatments were given. Owing to the scattered condition of the eruption three applications were made at each sitting, viz., chest, back and thighs, Each locality was rayed at one foot for ten minutes. The first application relieved the itching in a measure and after three treatments covering a period of eight days entire relief was obtained and the case discharged.
Case 4. This was also a case of psoriasis, the patient being a young man of thirty or thereabouts and of a decidedly neurotic temperament. The eruption was confined to the back and to the inner aspect of the thighs. At each sitting two exposures of fifteen minutes each were made upon the back and thighs respectively. Five treatments in all entirely removed disturbing conditions. During the progress of the treatments there was developed one of the chance by effects which have given a valuable hint in static treatment of neurotic patients. After the first treatment the patient repored that following the raying of the spinal column there occurred a particularly buoyant condition and a sense of exhilaration with an increased power of endurance. This result was not entirely temporary as at the end of treatment there was a sense of general well being such as had not been experienced for some time. Following up this hint I have in a number of neurotic cases employed a five minute raying of the spine at a distance of eighteen inches with most gratifying results. Granted that this effect may be psychic in a measure it has seemed to be none the less a beneficial one.
Case 5. This patient, a blacksmith by trade, was also referred to me for an obstinate attack of psoriasis occurring upon the back. The heavy underclothing and the perspiration incident to his occupation produced an additional irritation and the itching was nearly unbearable. In this case the eruption was confined entirely to the back which was generally covered with isolated patches. Exposures were made for fifteen minutes at one foot with a high tube. There were given in all six treatments covering a period of two weeks and a half at the end of which time the irritation disappeared and the skin regained normal conditions.
Case 6. This case was perhaps the most satisfactory of any that have come under my care, inasmuch as it was one which had been pronounced incurable both by general and special practitioners, indeed I myself, so he reminded me, told him some twelve years ago that I should have to give him up as a bad job. The patient was a man of middle age with the following history: He has always been a man of good and regular habits and up to the time of early manhood had been perfectly free from all abnormal skin conditions. At that time during a smallpox epidemic vaccination was followed by a succession of boils in various parts of the body which in turn were followed by an appearance of eczema first under the arms and latterly appearing successively upon various parts of the body, leaving one locality as it appeared in a new spot. All sorts of measures, local and constitutional, had been tried during the last thirty years without relief.
At the time of his consulting me (first) the eruption was confined to the posterior aspect of the legs and thighs extending from four inches above the knees to about the same distance below. The integument was dry, scaly and considerably thickened, itching was constant but particularly annoying at night when the clothing was removed and the surface presented numerous lacerations from unconscious scratching during sleep.
The surface of each leg was exposed at a distance of one foot for fifteen minutes. After a few treatments the skin gradually became somewhat more pliable and the irritation less marked. After the first half dozen treatments each sitting was supplemented with an application of the brush discharge from a wooden electrode with a metallic tip. From this time improvement seemed to be more rapid and at the end of the eighteenth treatment the case was discharged with perfect freedom from all irritation, the skin having assumed its normal thickness and pliability. The only measures other than electrical adopted in the treatment of this case was the nightly inunction with plain lanolin. The last treatment was given early in February and at the present writing there has been no return of abnormal conditions. The notable feature in the treatment of this patient was the more rapid progress after the adoption of the supplementary brush discharge.
Case 7. This young man, a painter by trade, had been suffering for nearly a year from an obstinate and painful dermatitis of the palms and palmar surfaces of the fingers following a specific infection. The entire palmar surfaces of both hands were covered with a desquamating epidermis closely resembling that following scarletina and which left behind it a tender red skin which in turn thickened, cracked and desquamated. There were also numerous deep and painful fissures bleeding at times. The whole condition was considerably aggravated by the nature of his occupation. Treatment was given three times a week with the tube at one foot from the skin and relief was soon manifested in the healing of the fissures and cessation of soreness, but desquamation again took place although this time leaving a more nearly normal surface. Continued treatment finally restored normal conditions after about three months.
One noticeable feature of this case was the entire absence of perspiration and to overcome this condition, during the latter half of the time the following expedient was adopted. An electrode conforming to the shape of the palms was made of two layers of thick tin foil with a layer of absorbent cotton between the two layers of foil to ensure perfect coapation to the irregularities of surface. By means of this electrode a ten-minute application of the Morton wave current was made at each sitting resulting in the production of a profuse perspiration, and from the time of the adoption of this measure, progress toward recovery became much more rapid.
Case 8. This case has proved to be the most stubborn as well as one of the most satisfactory in its ultimate result. The patient, a young lady teacher, has had for a period dating from girlhood, a particularly aggravated dermatitis of the palms, associated with a general anaemic condition. She was first referred to me early in the present year, having already had eight X-ray treatments at her home during the Christmas vacation, so that improvement had already begun and I did not have an opportunity to see the case at its worst. At this time the larger portion of the palmar surface of each hand was covered with a thick, dry, scaly epidermis, with numerous fissures, particularly about the roots of the fingers and in the folds between the thumb and index finger. The condition aside from being a painful one was the source of constant annoyance because of the unsightly condition of the hands. Two to three treatments a week were given with the high tube at one foot from the surface for fifteen minutes. Between Jan. 8 and March 29 eighteen treatments in all were given and at that time the left hand was entirely well and the right so nearly so that it was hoped that the accumulative effect of the treatments might carry along until normal conditions were established. However, this did not occur and early in May treatment was resumed, the lesion being confined to a slight roughness in the fold between the thumb and index finger of the right hand with one superficial crack. Treatment twice a week was given through May and the case was discharged June with an apparently normal integument upon both hands, a condition that has not existed since the first onset of the disturbance. As an auxiliary measure during the first period of treatment thin rubber gloves were worn at night and a local application to which she had resorted previous to treatment, consisting of a proprietary preparation, the principal ingredients of which appeared to be tar and glycerine, was employed. Constitutional treatment, the nature of which I am unfamiliar with, was kept up by her regular physician. During the latter period of treatment use of the high frequency current through a vacuum electrode was made supplemental to the regular raying with apparent advantage. Prognosis is at the present time doubtful but in any event there is a present freedom from all annoyance either from a physical or aesthetic point of view and to the mind of the patient at least the result has amply warranted the trouble and expense incurred in reaching it. Certainly up to the present all methods employed for relief had been futile until this one was employed.
A careful consideration of the method employed in the treatment of these cases would seem to bear out the idea suggested at the last meeting of this body, viz., the two-fold action of the ray depending upon the vacuum of the tube employed, and its analogy to, if not identity with the two-fold action of the crude and attenuated drug.
In a large number of varying conditions I have depended upon the tonic action of the ray from the high tube, in all cases avoiding production of irritating effect either from the low tube or the too frequent or too prolonged exposure to the high tube, believing this to be the logical and safe method of treatment. It is generally admitted that abnormal skin conditions as well as morbid growths depend upon a tissue condition of low vitality, and which yields to a degree a radiance short of that sufficient for the destruction of normal tissue. Furthermore there seems to be a primary tonic action of the ray far short of its destructive action which increases functional power in the skin and glandular organs.
A second deduction from cases observed would be the apparent increase in rapidity of improvement following supplementary treatment with one of the local static modalities.
As to means of exciting the tube the static machine seems to have the preference both from the fact that with this source of energy it is much easier to secure a uniform degree of radiance and from the possible additional benefit due to the induced current produced from the tube.
The question might arise as to whether the use of the X-ray should be classed with that of topical applications but to my mind none but an extremist could so consider it. One who would admit the germicidal effect and stimulating power of sunshine could not logically reject the selection of a definite light ray although produced by artificial means. Granted that to the homoeopathic physician the ideal method of cure is by internal medication there is in the use of the X-ray in conjunction with proper internal medication a cosmetic effect at least, which will not only redound to the credit of the physician but to the physical and mental comfort of the patient as well.