Two forms of apparatus are in use; one employing the static machine and the other, an induction coil with electric current or storage batteries attached. The coil is preferable and may have a double or triple winding in the primary, may be connected in parallel or in series and should furnish a 12-inch spark. Of the four interrupters that are in use, known as the turbine, the mercury dip, the electrolytic and the mechanical (vibratory), I prefer the last mentioned. A voltmeter, ammeter and tachometer may be used to indicate, respectively, voltage, amperage and frequency of interruptions. Lead plate is usually placed between the patient and the tube, an opening being made slightly larger than the area which is to be treated. Roentgen discovered that sheet-lead one-sixteenth of an inch thick was impervious to all rays, but in practice one thirty-second of an inch is sufficiently thick. The Friedlander shield, or similar hood or box, is a convenient method of protection when it can be used. Aluminium screens have been advised in the treatment of deep lesions, so as to intercept the superficially acting rays, which cause an early dermatitis.
The question of the condition of X-ray tubes is important. Tubes are known as “hard” and “soft.” The former shows marked resistance to the passage of the current because the vacuum is, relatively, more perfect. Its rays are penetrating, contain fewer of the superficially absorbed rays and hence the skin is not affected quickly, but only after a number of exposures. Naturally the characteristics of the soft tube are the reverse. Soft tubes are better suited for fluoroscopic work, because the contrast between flesh and bones is more evident. When possible a regulating device should be attached to all tubes, because they become hard from use, while rest will soften a hard tube to some degree. A new tube will give out more X-rays than an older one. Regarding the choice of tubes, it may be said in general that soft or moderately soft tubes are needed for the treatment of superficial skin lesions. However, a reaction should be anticipated and the treatment stopped, because a long continued raying is not necessary when a soft tube is used. For epithelioma, while a hard tube is preferable, the exact quality should depend upon the duration, depth and extent of the individual lesion.
Technic of X-raying hinges upon the choice of the fractional or massive dose methods. The former is largely used in America while the latter has long been employed in Europe. While some details concerning X-ray technic will be found scattered through the text, a brief outline of the differences in these methods will not be amiss. Schiff and Freund early devised a reasonable regime for the fractional method, without the use of instruments of precision. They suggested that the coil should furnish a spark gap of 30 cm.; that there should be a primary current of 12 volts and 1 1/2 amperes, with interruptions of 600 to 1,000 per minute; that the tube should be placed 15 cm. distant from the lesion treated, gradually reducing the distance to 5 cm.; that the time of the first treatment should be five minutes, which may be increased gradually to fifteen minutes; and that treatments should be given once, twice or three times in a week.
Methods for measuring the quantity and quality of the rays may be divided into the indirect and direct. The former depends largely upon the operator and is accurate enough for the fractional method but not exact enough for the more definite massive dose. The indirect method employs a milliamperemeter to ascertain the amount of current going through the tube, which is usually the same for each treatment. The spark gap is placed at a uniform, selected distance to register the resistance in the current and the anode of the tube is always located at the same number of inches from the surface to be treated. With these constant factors an experienced operator can approximately measure the quality (penetration) and quantity of the administered ray. While the direct method may utilize any or all of the factors just mentioned, it calls for the use of instruments which directly estimate the quality and quantity and is better suited for scientific work. Among the best instruments for the latter purpose are the Sabouraud-Noire radiometer and the Holzknecht radiometer. Among the forms of apparatus, designed to judge the quality or penetration of the ray, are the Benoist radiochromometer and the Benoist-Walter and Wehnelt scales. There are many other schemes devised for the same purposes as the ones mentioned and a number of combinations will prove efficacious if properly understood. Specific references will be found in the text to both the direct and indirect systems of measurement and to the fractional and massive dose methods but the reader must have recourse to a modern book on the X-rays for the details of radiotherapy.
Radium (radium-therapy) and other radioactive substances have been recommended and employed successfully in recent years in place of the X-rays. Becquerel rays is a term employed to describe those phenomena noted by Becquerel in 1896 when he demonstrated the radiating power of uranium and some of its salts. It might include the emanations and radiations given off by radium, which the Curies separated together with polonium from pitchblende. From radium and its salts are derived at least three varieties of rays, one has bactericidal and slightly penetrating properties, while the other two seem similar to the cathode and X- rays respectively. The action of radium, clinically and pathologically, is similar in many respects to the Roentgen-rays, and hence its use in all of the diseases which have been treated by the latter agency. Brilliant results have been reported from radium-therapy in epithelioma, tuberculosis cutis, eczema, nevi, pruritus and other diseases. I have employed in the past eight years specimens with a radio-activity varying from 7,000 to 600,000 units but at the present time limit myself in office practice to specimens of 200,000 units or more. The weaker preparations, being inexpensive and safer, may be entrusted to patients for home use with careful instructions. Radium may be applied in a properly shaped applicator or if on the surface, the containing glass or aluminium capsule or receptable may be fastened with adhesive plaster. The duration of the treatments varies from 20 minutes to two hours daily or less often.
Actionotherapy (phototherapy). The bactericidal properties of light have been known for many years but it remained for Finsen of Copenhagen in 1896 to demonstrate the practical use of light-therapy in cutaneous diseases. His method may briefly be defined as the focusing of concentrated chemical rays of light, deprived of their heat rays, on a small area. Exsanguination of the part treated is necessary to insure a deeper penetration of the light and to facilitate an acute inflammatory reaction. This is assured by compressors made of two quartz lenses, held together by a metal rim so as to leave space between, through which cold water constantly circulates to prevent the heating of the lens. The compressors are held in place by an attendant in Finsen’s Institute, but mechanical means are usually employed elsewhere to hold them in place. At first sunlight was used by Finsen but later an arc light of 60 to 80 amperes and about 70 volts was condensed, by a series of lenses inclosed in a metal tube which was filled with distilled water to absorb the heat rays. The lenses are made of rock crystal and the collecting lenses are 7 cm. in diameter. The rays are brought to a focus about six inches from the lower end of the tube. An outer compartment containing cold water surrounds the whole apparatus, thus affording additional prevention from overheating. Four patients may be treated at the same time by this lamp by placing a system of condensors in each quadrant of the circle.
In private work, the small lamp devised by Finsen and Reyn, which embraces the same system of condensors but consists of one lens of shorter focal distance, will suffice. In this variety the arc is so directed that the strongest rays fall directly on the first lens, and only 20 amperes and 55 volts are necessary. In all cases the light must fall perpendicularly upon the affected area which must be constantly exsanguinated. Lenses of condensors and compressors must be clean, and to this end they should be washed with antiseptic solutions after each treatment. Air bubbles should not be allowed on the lenses and the distilled water should be free from dust and dirt. Exposures vary from fifteen minutes to two hours, and are repeated when the reaction has subsided, which takes from one to two weeks. The reaction usually develops in six to twenty-four hours, and may vary from an erythema to a vesicular or bullous dermatitis. Necrosis of healthy tissue rarely results, hence scarring is absent or slight. Pigmentations and dilatation of superficial blood-vessels may persist beyond the ordinary time for resolution. The painlessness of actual treatment and the smooth, neat scars are points to be recommended.
American homeopath, he directed several hospitals in New York.
Professor of dermatology.
Served as Lieut. Colonel during the 1st World War.
See his book online: American homeopathy in the world war