Radiotherapy and phototherapy : including radium and high-frequency currents, their medical and surgical applications in diagnosis and treatment ; for students and practitioners

Front matter

HARVARD MEDICAL LIBRARY

RONTGEN

THE LLOYD E. HAWES COLLECTION IN THE

Preface

The new therapy, based upon recent discoveries in the domain of radiant energy, has already achieved such positive results in some hitherto intractable maladies as to warrant us in considering it a powerful addition to our armamentarium. Naturally this has stimulated an immense amount of investigation and experiment, so that the reduction of this mass of knowledge to a usable form and the elimination of faulty observation have required the review of a vast quantity of Kterature coming from all quarters of the civilized globe. Much that is incorrect has gained publicity and even credence. In order to secure adequate data on which to base a judgment of the actual merits and relative values of the various methods of treatment by light and rays, the author and those aiding him have endeavored to ascertain the truth, so far as possible, by actual work before committing any statement to print.

As several excellent books are already available upon the practical and technical side of radiography, this subject has been briefly treated in the present volume, and the space thus gained has been devoted to the newer, larger, and more important field of therapy. For similar reasons shadow pictures and elementary electrophysics have been excluded as foreign to the purpose of the work. High-frequency currents have been considered at length because of the newness of the subject, its comparative absence from American medical literature, and its close relations to other new methods here discussed.

vi PREFACE

The object of the book is distinctly practical, to enable the reader to secure for his patient the most prompt and permanent benefit. Accordingly, the author has especially endeavored, in the chapters on Cancer and on Skin Diseases, to indicate therapeutic measures of value aside from those directly related to radio- and phototherapeutics.

It should never be forgotten that forces so powerful for good may equally work harm if improperly applied. Cautionary directions are therefore freely given.

Decided advances have been recently made in the matter of exact dosage, a point quite as important as in the case of drugs. We can to-day apportion the dose necessary to be absorbed by the skin for the cure of many distinct diseases. Utility and exactitude have been the constant aim. Where the preferable technique differs from the usual it has been given prominence under each separate chapter.

The author desires to thank his many friends who have extended courtesies, but especially his former and present office associates. To Dr. Frankhn belongs the credit for most of the original drawings. Indeed, had it not been for his known abihty in electrophysics the work would not have been undertaken. Without the willing and able efforts of Dr. Stern the book could not have been completed and brought so fully up to the date of issue within the allotted time.

Acknowledgment is also made to the pubHshers for their

uniformly courteous and kind consideration and willingness

to carry out the writer's views.

C. W. A.

New York, July, 1904.

Introduction

The beginning of an epoch in medical science will always be associated with the name of Professor Roentgen. Intimately linked with his name will go down to future generations those of Finsen and Becquerel. Important as were the discoveries of methods of exploration of the great cavities of the body by auscultation and percussion, they appear to us to-day to recede into secondary positions, when compared with those newer methods which permit the eye to do or to aid materially the ear in doing what was formerly left to the latter alone. Great as have been the benefits to humanity from the newer methods of exploration in surgery made possible by his discovery of this new force, their extension to non-surgical conditions and the development of a wholly new method of ray treatment bid fair to confer a still greater boon.

Few great discoveries in the realms of science have come so suddenly and seemingly so unheralded into a field of practical utility. Still if we pause for a moment to consider these startling and sensational phenomena, bursting, as it were, from the confines of a Crookes tube, and if we bear in mind the years of painstaking experimental work preceding and leading up to what seemed almost an accidental discovery on the part of Roentgen, the subject takes on a wholly different aspect, and we ask ourselves the question, "Why was not this new form of energy discovered earlier in the world's history?

In a review of the scientific labors which preceded those of the discoverer we perceive that for years Geissler, Crookes, Hertz, Lenard, and Hittorf were preparing the way. It

18 INTRODUCTION

was left to Roentgen to take that one necessary step in advance along the path of light which had its beginning in V. Guericke's electric spark, and whose whole extent was refulgent with the brilliancy of discovery of such men as Keppler, the father of the modern science of light; Wallaston, whose substitution of the slit for the round hole made possible the science of spectroscopy; Sprengel, Boyle, and Hawksbee. The beautiful experiments made by Crookes in demonstration of his theory of radiant matter, though combated by Lenard, went far toward that culmination of work upon these lines which fell to the lot of Roentgen. Indeed, had not Crookes persisted in his work under the stimulation of attack and proven his theory, the brilliant discovery to which it led might have been delayed many years or even indefinitely.

At about the same time that Roentgen surprised and edified the world with his announcements, Finsen, of Copenhagen, entered upon a line of treatment by light whose benefits, though almost restricted to that form of skin-tuberculosis known as lupus, is nevertheless remarkable in the fact that pathological conditions hitherto practically incurable and most disfiguring withal are now cured.

Becquerel, inspired by the achievements of Roentgen, entered with renewed vigor and confidence into his investigations of the luminous properties of phosphorescent bodies, and finally in 1896 announced his discovery, which may be said to have inaugurated the science of radio-activity.

The new ray now known by his name has been found to possess most remarkable qualities, and to be capable of producing decided therapeutic effects. Thus there have arisen three methods of treatment by light which are so intimately associated in their natures, origins and results that they can well be studied together.

If we consider these new forces in association with recent discoveries in the application of electricity and especially the currents of high frequency to various pathological processes, we have, as it were, a new practice of medicine.

The therapeutic application of high-frequency currents or d'Arsonvalization has attained such importance, and can be employed oftentimes with such advantage along with

INTRODUCTION 19

the more strictly speaking light methods, that its consideration in association with them here seems not inappropriate. Though exaggerated optimism should be warned against, still it seems to me the time has arrived when we must lay aside doubts, fears, and prejudices and realize that we are entering upon an entirely new era in the science of medicine, whose horizon grows brighter the more we strive to penetrate it. Our present efforts will be largely expended in a study of these newer agencies as applied to the detection and cure of disease. Nothing need be said of the numerous workers in these new spheres of discovery. Their achievements are of themselves far too luminous to require any laudatory remark, and no brilliancy of verbiage could add to their lustre.

NOMENCLATURE.

The many names applied in connection with light and ray matters, and the careless manner in which terms are sometimes used, makes it necessary to define clearly the meaning of the various neologisms employed in this volume.

When the term x-ray is used it always means the ray of unknown quantity so designated by its discoverer, Professor Roentgen, and not any of the other rays connected with radio-active substances which have been likewise called "x,"

The cathode ray means, unless otherwise explained, that formed within a Crookes tube, and taking an essential part in the production of the x-ray.

Radio diagnosis, radiopraxis, radiotherapy, radiography, etc., refer to the methods in which Roentgen's ray are utilized. While it is proper to employ the same terms for effects produced by radio-active substances, too little has, till now, been done in this direction, and the faulty use of these terms might confuse.

Phototherapy refers to treatment by light in general, and to that by the Finsen light and its modifications in particular— but not to x-ray treatment.

Heliotherapy, on the contrary, means treatment by light of the sun in its various applications other than those devised by Finsen.

20 INTRODUCTIOX

Finsen^s method, treatment, etc., are terms restricted to his original or actual recommendations and technique, and do not apply to phototherapy in general. They refer especially to his plan of focusing sun and arc lights specially produced, before they reach the surface to be affected.

Actinotherapy relates to the various methods in which the actinic or chemical rays are known to be or thought to be the effective agent, in treatment by violet or ultraviolet rays, including the methods of Finsen and his followers.

Skiagraphy can be employed synonymously with radiography just as we speak of photography, telegraphy, etc.

Chromotherapy. This term has been employed for treatment by variously colored lights such as red, blue, etc. It is not strictly proper to employ it in connection with Finsen' s treatment of the suppurative stage of variola, for here it is not so much a treatment by color eft'ects, but an exclusion of the irritating actinic or chemical rays.

Light treatment has been much employed as a term for the use of therapeutically active rays— blue, visible violet, ultra-violet or actinic — but it is too indefinite.

High-frequency currents in therapy are those currents •^dthout evident polarity, but of enormous frequency and possessing oscillations whose rate is too great to be appreciated by human senses.

D'' Arsonvalization is a method devised by d'Arsonval of apphing these high-frequency currents in a closed circuit without producing any sensation.

Becquerel rays are those named after theh discoverer, the French scientist, Henri Becquerel. in 1896, and refer to the radiations emanating from uranium, radium, polonium, thorium, etc.

Radio-activity is the acting force of these radiations, and the term is used to denote the comparative strength of the emanations, with uranium as a standard.

Histofluorescence. The production of fluorescence in the tissues of the body by the administration of various substances before exposure to x or other rays.

Part I

GENERAL CONSIDERATtONS UPON RADI- OLOGY. THE HISTORY AND NATURE OF THE X-RAY AND THE METHOD OF ITS PRODUCTION.

Chapter I. History And Character Of The X-ray

HISTORY.

Roentgen or x-rays are generated in a vacuum tube of the general type of that invented by Geissler, and afterward extensively employed and modified by De la Rue, Spottiswoode, and many others, but particularly Crookes, Lenard, and Roentgen. The discovery of the x-rsij, while it burst upon the world without the least warning, and completely astounded the most astute and learned physicists of the time, was only the natural consequence of a series of discoveries that were rewarding a few earnest workers who were persistently following the clew that Geissler had laid bare when he discovered that in the partial vacua of different gases, the electric discharge is very different from that in air, which was disruptive and called a spark. Thus it was first noted that the colors emitted by the "tube" changed with every variation of the vacuum within, and with every different gas that the tube contained. Then it was discovered that the discharge, or presumably the matter remaining within the tube, divided itself into disks or striae, of different shapes and sizes depending upon the state of the vacuum and the potential of the discharge, and that the spaces occupied by these differently colored bodies exhibited various conditions of resistance. Following this came the discoveries of Crookes, " the most important •of which was, that a stream of some kind emanated from the negatively attached pole or cathode of the tube and flowed across the tube to the positive pole, or the anode. He later discovered that this stream was propagated in straight lines, by the following experiment: In a tube of the shape shown in Fig. i was placed a cross made of mica, in such a position that the stream from the cathode would encounter it on its way to the glass side of the tube opposite. When the tube was excited by a suitable discharge of electricity it was seen that the mica cross, which

Fig. I.

Crookes' experiment.

evidently occluded the stream, cast a sharp and clear shadow upon the glass side of the tube. It was noted at the sam^e time that the glass fluoresced brilliantly wherever the stream impinged. Later the same observer discovered that the cathode stream was capable of being transformed into kinetic energy, and he demonstrated this by means of an ingenious glass railway that he had constructed. The form of this is shown in Fig. 2. The small wind-wheel is supported on an axis passed through the centre and protrudes on both sides, where it may run on the glass rails. Now if the cathode stream is so directed that it strikes the top of one of the mica vanes of the wheel above the axis, it will cause the wheel to revolve toward the anode, indicating that the vane of the wheel is repelled by the stream.

\ The motive power of the cathode stream was further shown by the following simple experiment: In the centre of a vacuum tube was suspended a small screw propeller. The cathode stream was directly in a line with the axis of the propeller, and when the current was allowed to flow the wheel turned as would a turbine. To show that the action of the cathode stream was propulsive, Crookes constructed a tiny weather-vane in a vacuum tube, and when the vanes were connected with the cathode, the streams flowing from the surface in one direction caused the wheel to rotate in the opposite. The speculations of Crookes as to the nature of the phenomena which he had discovered in these tubes led him to the conclusion that there existed

Fig. 2.

Crookes' experiment.

a new state of matter which he called radiant matter. This name seems to have been selected unfortunately in that it was fiercely attacked by a great many of the scientific men of the time, who endeavored to prove that the theory amounted to nothing.

It is well, however, that this difference in opinion existed, because it is almost directly due to this fact and the disputes engendered that the Roentgen rays were eventually discovered. Crookes' greatest opponent was Lenard, in France, who performed many experiments with the object of disproving the theory that Crookes had advanced as to the nature and causation of his phenomena. The most important discovery of Lenard was that the cathode stream could be detected outside of the tube as well as within, and that the stream was capable of being deflected or attracted by a magnet. There were many others who were engaged in research along the same lines, and almost every day some new fact was discovered bearing upon the peculiar effects of the electric discharge in more or less complete vacua. When on November 8, 1895, William C. Roentgen, a professor of physics in the University of Wiirzburg, in Bavaria, discovered that a great many photographic plates which were within the range of the rays from a Crookes tube with which he was making some experiments were spoiled or fogged, although they were amply protected from light by regular plate-holders, it was at once suspected that the cause of the chemical action on the plates was due to the peculiar radiations from the tube. He was strengthened in his suspicion by finding shadows of the forms of various objects which had lain upon the holders, over the developed plates. He had noted a short time before that the rays that emanated from the tube were capable of causing fluorescence in certain salts, and this fact combined with the evident effect on photographic plates, encouraged him to go farther into the matter and directly experiment with these newly observed rays. These observations led to the discovery that the rays could pass through black paper that was totally unable to transmit the ultra-violet or other chemical rays of the sun or arc light, and then cause platino-barium cyanide to fluoresce brilliantly; that the radiation was capable of passing through the thick, black cardboard covers of the plate-holders and affect the plates within; that the radiation was capable of acting through many substances and causing fluorescence on their emergence, these substances being totally opaque to ordinary light and the ultra-violet rays; and that the transmissibility of the substance to the rays had a relation to the specific density of that substance. The reason for this was at the time not quite clear. When Roentgen read his first paper, announcing his discovery, in December of the same year, he had already experimented with many substances to ascertain their perviousness to the new form of radiation, and was able at this early date to give considerable information on this subject.

In the tube with which the work of Roentgen was performed the cathode consisted of a plate of metal from which the rays travelled in a straight line and struck the glass side of the tube opposite, at which point the new rays were generated. The effects that Roentgen observed were clearly not due to the cathode stream, as he found that they differed from the latter in that they were not capable of being reflected, refracted, or polarized, and were not affected by a magnet, or capable of discharging negatively charged bodies. The rays were further distinguished from ultra-violet rays among other ways by the fact that the ultra-violet rays are capable of discharging either negatively or positively charged bodies; of being regularly refracted, reflected, and polarized; also in the fact that there were bodies which the rays would not traverse, some being substances that readily transmitted the ultra-violet rays, such as rock salt.

The theories that were advanced to show the position of the x-ray in the physical firmament were at first numerous, but are fewer now. The most important among those first advanced was that of Roentgen himself, that the rays were a short form of longitudinal vibration in the ether. Later this was totally abandoned in favor of the two views which now hold the field. The first of these is the theory that the rays consist of minute particles or ions, projected into space at an enormous velocity; and the other, that the rays are short transverse vibrations of the ether, similar to those of light, but infinitely shorter than the latter, and that they occupy a space in the spectrum of ether vibrations, beyond the Becquerel rays. The latter theory, while it is far from being satisfactorily confirmed, and while the emission theory has many strong points, seems destined to hold the field to the exclusion of all others.

While a discussion of the many theories cannot here be entered into, an attempt will be made in another chapter to give an insight into what has been accomplished along these lines.

CATHODE RAY.

This ray, which was discovered and named by Crookes, plays a very important part in the production of the :%--ray.

It is the ray which, given off from the cathode, strikes the target of the anode and is there converted into and sent forth from the tube as an x-ray.

Cathode rays are thrown off as particles from all highly heated and highly electrified bodies.

According to Vihard, they consist of a stream of hydrogen corpuscles negatively charged, moving at about 70,000 miles per second.

This molecular bombardment within a Crookes tube can cause phosphorescence of various substances. Some German physicists believe that these rays are due to longitudinal vibrations, but J. J. Thomson's theory, that they consist of a shower or stream of corpuscular particles striking the anode, is the explanation generally regarded as correct.

The cathode has an exaggerated saucer-shape to converge the rays to a point on the target and to counteract the tendency of the particles making up the stream to repell one another. They are clearly visible in a very low vacuum tube, generally coming to a focus before they reach the anode, when they do not cross one another, but converge to form a pencil-like stream and continue in a straight line until they meet an obstruction.

At times, beyond the focus point, the stream may seem to widen, making a second funnel whose base includes and often passes beyond the anode, so that the latter does not intercept all its rays. As the vacuum increases the focus moves toward the anode.

That Roentgen rays can be converted back again, so to speak, into cathode rays has apparently been demonstrated by Hammer.

By bombarding the outside of an Edison tube with x-rays, he found that cathode rays are stimulated in its interior, causing tungstate of calcium to become brightly phosphorescent.

Rudis-Jicinsky says that to get the anodyne effects in treatment we must have an abundance of cathode rays which are changed into the unknown rays. The x-rays alone or the cathode rays alone are not sufficient. The cathode rays may be deflected by a magnet or they may pass through substances opaque to Hght, and they may cast shadows of objects less opaque. They possess the property of acting upon photographic plates. They will pass in straight lines, independent of the position of the anode. In very low vacua they exhibit a beautiful violet color. They produce fluorescence of the tube or of certain objects contained within the tube, and their main difference from the :x;-ray consists in the fact that they may be focused.

The cathode rays are similar to the ultra-violet rays in that they will not affect the deeper tissues, nerves, or nerve centres, unless the parts are first deprived of their usual blood contents.

It is generally conceded that all possible therapeutic effect of the cathode ray is lost because of its non-emergence as such from the tube.

THE NATURE OF THE X-RAY.

The so-called .%^-ray is a form of energy manifested in its action upon certain unstable chemical compounds in which it produces chemical changes, and on certain salts in which it produces brilliant phosphorescence.

The mode of transmission of this energy and its nature are matters of some importance and great obscurity, though there exist several plausible theories. All these, however, lack confirmative basis, owing to the limited amount and indefinite nature of our present knowledge. The :x;-ray, although itself invisible, is at times spoken of as light on account of its ability to produce light in certain fluorescent substances, and because of its chemical action being in a measure similar to that of light; at least in so far as results obtain.

The x-ray is produced by passing electric discharges of tremendous potential through gases at different degrees of attenuation.

The latest point of interest in the controversy, as regards the nature of the rays, is the statement of Lord Rayleigh, Professor of Natural Philosophy in the British Royal Institution, who has announced that M. Blondelot, a skilful French experimenter, very recently adduced evidence going far to prove that the Roentgen rays are susceptible of polarization, if they have not been already polarized, and can therefore be traced in the solar spectrum. If this is true, and the rays are transversal, as M. Blondelot thinks, it follows that they are a form of ordinary light, but of extremely short wave-length, perhaps a hundred times shorter than visible light waves.

Lord Rayleigh said that he saw no reason to question the discovery, which is of great importance in aiding to determine the nature of the x-rays, which has been a matter of doubt ever since their discovery.

As to the nature of the light itself, if it is in reality proper to speak of its application as a form of light treatment, very little more is known to-day than when the rays were first discovered. Of the two surviving theories, that of extremely rapid wave vibration seems to have the greatest number of supporters. The fact of the vibratory nature of Herzian and electric phenomena, and the more recent placing of the Becquerel rays in the wave-gamut, make a sequence beginning with the Herzian waves on the one hand, and sliding by fine gradations, successively through the electric, heat, light, actinic, Becquerel, and, lastly, the x-rays, and offer a tempting scientific classification which seems rather convincing. When taken in connection with the various other phenomena which point in the same direction, it appears almost inevitable that the x-ray should find its proper place in the vacant space which has apparently existed in the scale of ethereal vibrations. It is interesting to note in this connection that Goldschmidt has amply demonstrated that a thin layer of ultra-violet light is generated at the point of impact of the x-ray within the tube, but he denies that the chemical action of the ray is due to this agent, having experimented amply with ultra-violet rays otherwise generated.

In the evolution of the cathode ray it would seem that its component atoms are broken up into one larger portion immobile and positively electrified, and a smaller portion negatively electrified, which by its rapid flight produces the phenomenon known as the x-ray. It is not some form of electricity, but is a higher rate of vibration even than light — it is the transformed energy of the electric current.

Pratt claims that it is a form of electric energy.

Many physicists, including Thomson and Stokes, believe that the ray is an irregular electromagnetic wave as compared with light, which is of a regular recurrence. A great many German scientists claim that the phenomenon is due to longitudinal vibrations.

Heidingsfeld^ believes that the :\:-ray consists of minute particles of platinum, in a very high state of "radiant" excitation, emanating from the enclosed disk and moving radially with sufficient velocity to readily penetrate the circumscribed glass enclosure and all exposed soft and fairly hard substances. He thinks that this theory is to a degree confirmed by the close analogy that exists between the :x;-rays and the rays emanating from uranium, radium, pollonium, and other allied substances. An objection to this view lies in the fact that rays may be generated in tubes without metallic anode.

The reason these waves cannot be reflected is probably that they are so small that no polish which we can secure upon a surface can turn them back.

The cathode rays in striking the anode are deflected and not reflected.

The x-rays are capable of discharging electrified bodies; they accomplish this by making the air through which they pass a good conductor.

We find that they not only act at the site of entrance, but also at the site of exit. As regards the way the rays act upon living tissues, it is undoubtedly a reducing or chemical action, very similar to their effect on photographic plates.

x-rays, radium rays, or Becquerel rays have one property in common, and that is they all show their effect in the distance without affecting the media through which they pass.

Eder and Valenta have proven that only plates prepared with gelatin show results in x-ray photographic work; those prepared with collodion show little or no result.

^ Journal of Cutaneous Diseases, January, 1904.

The lighter the specific gravity of a substance, the easier it is penetrated by the :x;-rays, but it also depends a great deal upon the thickness of the substance. V. Novak, Sule, Voller, and Walter have proven that the penetrability of substances to :x:-rays depends more on their atomic weight than on their density.

Lead, platinum, and gold are almost impenetrable to the rays. Zinc, ' nickel, iron, and chiefly mercury are very difficult of penetration. Glass vi^eakens the rays much more than the same thickness of aluminium.

Chapter II

APPARATUS— METHODS OF PRODUCING THE RAY- MEASURE OF CURRENTS— PHYSICS OF THE RAY— TUBES AND ACCESSORIES.

STATIC MACHINES.

We will first consider the static electric machines. These are of three general varieties, as used at present, the Holtz, Toepler-Holtz, and the Wimhurst. The first two are used principally in this country, while the last is used chiefly in England. In other Continental countries of Europe the use of the static machine is almost unknown.

The Holtz machine was invented in 1854, by Holtz, of Berlin, who introduced it as a vast improvement upon the friction type of machine which had grown out of that invented by Hawksbee. The Holtz machine was indeed a wonderful invention, and was so far superior to the friction-plate apparatus as to completely supersede it. It possessed two inherent weaknesses, however, which, notwithstanding its many advantages, such as tremendous power and ease of operating, etc., rendered its use limited, and these were that it was not self-charged — i. e., before starting, it had to be separately excited by another body which had been electrified. It was in every respect an influence machine, or, more plainly, an inductive machine, and for this reason the second weakness, that of susceptibility to moisture, became evident. The machine did not operate, except in the driest of weather.

The Toepler-Holtz added to this machine certain improvements, in the shape of metal disks set in the revolving plate, with metallic brushes, causing to communicate disks at opposite points upon the periphery of the plate. The friction of these brushes caused the machine to become self-exciting. The influence of the atmosphere was, however, quite as much felt in this type as in the older machine, with the added disadvantage that the machine current, being made up of a series of pulsating charges, would frequently, on account of slight interruptions, alter its polarity, even while running, and thus cause very serious inconveniences when used for delicate work or experiments.