Title: Roentgen-rays in the treatment of skin diseases and for the removal of hair. July 1900 (J Cutan Genitourin Dis).
Authors: Pusey WA
Journal: Reprint: Arch Dermatol 1983 Feb;119(2):162-77
PMID: 6337564, UI: 83125647
Read before Chicago Medical Society, March, 19oo.
PERHAPS no more unexpected accidents ever happened than those which were announced upon the very heels of the first use of x-rays. It was as astonishing as the rays themselves that exposure without painful sensation, to what is apparently a form of light, could cause damage to tissues, which under certain circumstances might amount even to necrosis. There is no analogous clinical fact from which the occurrence of the severer forms of x-ray injuries might have been foreseen. It was a new phenomenon. There was at first no thought of caution and, as a result, reports of injuries came thick and fast during the early and enthusiastic use of the rays, so that it did not take long for all the forms of injury which are now known, to be reported. Indeed, about all of the injuries of consequence that have occurred, occurred during this early period of incautious use.
These effects of x-rays upon the skin and subcutaneous tissues were soon found to be of the following kinds : I. — Changes in the epidermis itself or in its appendages: (a) pigmentation; (b) blanching of the hair; (c) outfall of the hair; (c/) trophic changes in the nails similar to those in the hair, sometimes resulting in interference with growth, and in severer cases in shedding of the nails. II. — Changes in the corium and subcutaneous tissues. These are all inflammatory in character, varying from slight erythema through all degrees of dermititis up to necrosis.
It is not surprising, with results of this sort testifying to the influence which x-rays are capable of exerting upon the nutrition of tissues, that the possibility should suggest itself of utilizing such an agent for therapeutic purposes. The two actions of x-rays on tissues which offered the most promising prospects of utilization for therapeutic purposes were: I. — Its power of causing the falling out of the hair, and II., its power of producing inflammatory reaction and influencing the nutrition of connective tissue.
A method of removing hair conveniently and thoroughly and without pain is a desideratum in the treatment of a number of diseases. If the method could be so developed as to furnish a means of permanently removing hair it would have a most valuable field of usefulness in the treatment of cosmic defects. There is also a wide range of usefulness for an agent capable of influencing the nutrition of the connective-tissue structures of the skin, particularly if it may be so managed as to exercise some selective action upon tissues of low degree of vitality.
The problem of utilizing these properties of x-rays for therapeutic purposes has involved not only the determination of the effects of x-rays upon tissues of various sorts, healthy and diseased, but the
determination of the conditions under which the desired results might be attained within the limits of safety. A number of experimenters have engaged in clearing up these questions. The results which have been attained by various workers in establishing the conditions of safety of the use of x-rays for diagnostic purposes have furnished many of the data which have been utilized in working out the problems of the use of x-rays for therapeutic purposes. Among the workers who have especially devoted their attention to the problems of the therapeutic uses of the x-rays, SchitY and Freund of \’ienna deserve first mention. Among others who have contributed to this are Albers-Schonberg
Jutassy. Kiimmell, Rieder, ^liisham and others in Germany and Austria. Outside of Germany and Austria, where most of the investigations have been made, there should be mentioned Holland of England, and P. M. Jones of San Francisco, who as far as I know is the first American to have done any work in this line. The credit for first demonstrating the possibility of using x-rays for therapeutic purposes belongs, I believe, to Freund, who, after a consideration of the alopecias accidentally produced by x-rays, undertook in November. 1896, to remove the hair from a naevus by their use. Following Freund, Schif? a little later suggested the use of x-rays for the treatment of various diseases of the hair and for the treatment of lupus.
Treatment by exposure to x-rays has been applied chiefly in four classes of affections :
I. — In hypertrichosis, for the removal of undesirable hair.
II. — In diseases of the hair and hair follicles, such as sycosis, tinea, tonsurans, favus, where the removal of diseased hair is an essential part of treatment.
III. — In the treatment of inflammatory aflections. like chronic eczema, where the purpose is to stimulate the tissues and cause absorption of inflammatory products.
IV. — In certain specific aflections, like lupus, where it is desired to cause destruction or absorption of tissues of low vitality.
As already mentioned the first attempt to apply x-rays for therapeutic purposes was an effort by Freund to remove by -this means the hair from a naevus. In the three years since this first case Schiff and Freund have applied this method of removing hair to many cases. Many of their cases have now remained free from the recurrence of hairs for more than a year. Jutassy of Buda-Pesth has also applied this method of removing hairs to a large number of cases. He has reported forty cases of successful removal of hair by this method, some of which were treated more than a 3^ear before the report was made,
and had shown no regrowth of the destroyed hair. An interesting case confirmatory of the claims of Freund and Jutassy is reported by Neville Wood of London in the Lancet of January 27th of this year. Treatment by x-rays was undertaken in order to remove a profuse growth of down and large hairs. In Wood’s case the chin, the part which had been thoroughly treated, remained eight months after cessation of treatment “quite free from down and hair.” My own experience with the method is not long enough to allow any statement as to the permanency of the results in cases of this character, but it has demonstrated that by Freund’s method of treatment with a very weak, but definite current, the hairs from an entire area can be successfully removed.
The removal of hair by this method is attended by no disagreeable sensations and by no accompanying symptoms beyond at times a slight erythema or pigmentation, lasting a short time. The skin, after removal of the hair, is left in the same condition as before, except for the absence of hair. There seems every reason to believe that in x-rays we have an agent of the utmost value for the removal of hair. It is painless, not nearly so tedious as electrolysis, and can be applied to the hairs of a large surface at one time. When there are only a few large hairs to be removed electrolysis will still be probably the more convenient method, but there is no comparison in convenience between the two metliods for taking off a large number of hairs from any given area. For instance all of the hairs from the back of the forearm can be removed together. The method is particularly adapted to cases in which it is desired to remove down and profuse growth of hair.
The mycotic diseases of the hair and hair follicles, such as tinea tonsurans, favus, and sycosis are among the most intractable diseases that the dermatologist is called upon to treat. The difficulty is in getting at the peccant organisms. In practically all methods of treatment of these affections the first essential is thorough epilation. But thorough epilation is easier said than done, for, leaving out of consideration the pain and tediousness of it, the difficulty of epilation by mechanical means is that in the diseases where it is indicated the hairs become fragile, or so macerated and weak that in the attempts at epilation they break off, leaving in the follicles the diseased bulbs and broken hair shafts, filled with the organisms almost out of reach of one’s remedies. In the treatment with x-rays this difficulty seems to be overcome in an ideal way. The hairs become loose and are removable without force. It is probable too that the effects of x-rays are not limited to their depilatory properties. The clinical course of the cases is such as to indicate that the rays have a marked bactericidal effect, due either directly to the rays or to the stimulation of the tis- sues with the accompanying increased phagocytosis which the rays cause. In sycosis in particular the method has proven successful.
It is conceivable that this method could be applied in all conditions where epilation is needed. It has been applied with success by Gocht, in wounds of the scalp in which healing was prevented by growth of hair into the wounds. It has not, so far as I know, been applied for the removal of hairs in trichiasis or for the removal of hairs for any purpose about the eyelids.
Upon the subject of the treatment of eczema by exposure to x-rays there are a number of reports testifying to the favorable results. Albers Schonberg has reported three cases of chronic eczema healed unusually rapidly under this treatment. Hahn has reported similar cases, and Mackey two of intractable chronic eczema which showed very great improvement under this treatment. Others are to be found in the literature. The cases of eczema in which this method of treatment seems to have a field of usefulness are very intractable circumscribed patches of chronic eczema in which there is necessity for marked stimulation of the skin in order to get absorption of the inflammatory products. There seems no ground for believing that the method will have more than a very limited field of usefulness in the treatment of eczema.
When we come to the treatment of lupus vulgaris by x-rays we perhaps reach the most interesting part of the subject. Upon the use of x-rays in the treatment of lupus we have favorable accounts from many quarters. Schift’, who with justice, I believe, claims priority in the treatment of lupus by this method, has treated many cases in this way and has published a number of cures. His first case showed, one year after healing, no recurrence of lupus in the areas which had been treated, while lupus foci in the areas which had not been treated liad increased. Kiimmell has reported sixteen cases which he had treated by this method. Of these, two did not continue treatment long enough to give the method a trial. In one, a lupus of the finger, the lupus entirely healed, but the finger was afterwards amputated for disease of the bone, the skin being healthy. The healing of the skin lesions in this case, while the deeper structures remained unaffected, is an interesting observation confirming’ the experimental observations of Rieder and others that the rays are effective against superficial tubercular lesions while they cannot be used safely in sufficient strength to affect deep-seated lesions. To continue with Kiimmell’s report, two patients were under treatment at the time of the report and were showing satisfactory progress. The only case in which no improvement had occurred under this treatment proved to be a case of syphilitic ulceration which healed promptly under antisyphilitic treatment. The ten remaining cases had been cured. These were cases of lupus of severe type, which had previously undergone various sorts of treatment, including in some cases treatment with tuberculin. Some of the cases have remained healed many months after cure by x-rays, and in none of them has any tendency to recurrence developed. To use Ktimmell’s words, in every case which he had handled “improvement had followed, and, with sufficiently long treatment, healing, which has continued until the present.” This showing of Kiimmell’s, of ten cured, and no real failures to be charged against the method in sixteen cases, is certainly interesting. Albers-Schonberg has reported two cases cured. The first case, a man of twenty years with lupus of the face and nose, was completely cured and showed no recurrence a year afterwards. The second, a woman of forty-eight, with lupus of the face, was cured after six months’ treatment. Gochtlias reported one lupus cured.
Holland of England has reported three cases of tuberculosis of the skin or lupus in which he has used x-rays. The first, a tu1)erculous ulceration of the foot of eleven years’ duration, which had resisted various forms of treatment, after two months’ treatment with x-rays showed great improvement and bid fair to get well. In his second case, a lupus on the left side of the face in a boy fifteen years old, in which the usual methods of treatment had failed, treatment by this method was followed after two months by complete healing. There had been no recurrence up to the time of his report of the case. His third case, a lupus of similar character of eleven years’ duration in a boy, which had proven intractable to most vigorous treatment, had shown great improvement after one month’s treatment and at the time of his report seemed as if it would result in complete cure.
Phillip Mills Jones of San Francisco has reported two cases of lupus treated in this way. l”he first, a man of fifty-five years, with an intractable lupus on the forehead of twelve years’ duration, was put on this treatment in January, 1899. I” ^^ur weeks the lesions exposed were healed. One ulcerating point had been protected from the rays for the purpose of a control observation ; when the other areas had healed, this showed slight increase in size. This patch healed after three weeks of treatment. There had been no recurrence of disease up to the time of his report, January 6 of this year, though the lesions had never remained healed before for more than three months. The observation upon the healing of the exposed lesions and the persistence of the patch not exposed is similar to one made by Schiff in his first case already referred, to and furnishes convincing evidence of the direct influence of x-rays upon lupus. Jones reports a second case equally as chronic and intractable in which some areas have already healed, and others now under treatment show every indication of favorable results. These cases of Jones’ are, I believe, the first in this country in which x-rays have been used for the treatment of lupus, or indeed for any therapeutic purpose.
These results, coming from so many different sources, are striking enough to command attention. They justify the hope that in the proper use of x-rays we have a remedy of the greatest importance in this intractable disease. The advantages which this method seems to offer for the treatment of lupus may be briefly summarized as folloAvs :
1. Eflicacy : Practically all of the cases which have been treated by this method have been of grave, persistent character and had resisted recognized forms of treatment for years. The diagnosis in practically all of the cases is above question.
2. Freedom from pain : ^M^en one remembers the various other plans of treatment, with the never-ending repetition of painful procedures in the severe cases, such as those in which this method has been used, the fact that this method is practically painless appears as an advantage of no small consideration.
3. The character of the scars : All observers agree upon the excellent character of the scars following this method of treatment. They are .soft, pliable, and thin, and nearly approach the normal skin in appearance.
The other method of treatment which this one approaches most closely and with which it must bear comparison is Finsen’s treatment by the ultraviolet rays of white light. The two methods are similar in using for destruction of the lupus tissue actinic rays of high value. There are the best reasons for believing that the methods are identical in principle, one using highly actinic rays, derived from white light, the other similar or identical rays which are found among the x-rays. The results attained by the two methods are strikingly similar and are a further argument for the similarity or indentity of the essential agents. The advantages which the x-ray method offers are in the way of convenience and rapidity of results. Finsen’s method of treatment is inconvenient and excessively slow. Under his method patients have daily sittings of about two hours, and in an hour it is only possible to treat an area of a little over half an inch square. The time required for the treatment of a case extends over about two years. With the method of treatment by x-rays, on the other hand, the sittings are short — only a few minutes daily — and an area of lupus involving the entire side of the face for example can be treated at one sitting. The results further are obtained in a few weeks or at most in a few months.
As to lupus erythematosus, Schiff and others have reported cases cured by this method; there are not, however, enough data available at present to form any opinion as to its value in the treatment of that disease.
The method has been tried in various other diseases, acne, psoriasis, epithelioma, but the affections which we have already discussed are those in which it offers the greatest prospects oi usefulness. There is no ground for believing that in this method we have found a panacea for skin diseases.
A consideration of the effects of x-rays upon tissues does not leave us altogether in the dark as to the reason for these results. The condition of tissues affected by x-rays has been studied histologically by several observers; among others by Gilchrist and Kibbe in cases of x-ray dermatitis, and by Oudin, Barthelemy and Darier, in x-ray baldness. These observers agree that the most marked changes are found in the epithelial structures. The growth of the epidermis is influenced in a remarkable way. There is great increase in the thickness of all of the layers of the epidermis, particularly of the mucous layer, increase in the amount of keratohyaline and pigment, and evidences of greatly increased karyokinetic activity, all going to show that there is marked stimulation of the activity of cells. The studies made by Oudin, Barthelemy and Darier — in which the histologic studies were presumably made by Darier — were made upon guinea-pigs in which baldness without dermatitis had been produced ; and the findings are particularly interesting. Histologically the tissues showed :
I. — Enormous thickening of the epidermis in all its layers.
II. — Atrophy of the hair follicles, which in places had entirely disappeared.
They conclude: “The thickening of the epidermis in all of its layers, the increase of keratohyaline. and the quite extraordinary atrophy of the follicles may be viewed as a reaction against an irritant of unusual strength. This irritant appears to increase the vitality of the least differentiated skin elements while the differentiated elements, hair, nails, and glands undergo retrogressive changes and atrophy. Of the hair follicles only traces remain, one or at most three in a microscopic field, and these are no longer follicles, but only conical prolongation of epidermis which dip down seemingly only half so deep as normal follicles. Of hair papilla, or regeneration bulb every trace is lacking.” Bearing these observations in mind the statement that permanent removal of hair may be caused by exposure to x-rays loses some of its startling character.
The changes in the corium are those of an ordinary inflammatory process without peculiar features — to quote Kibbe: “Capillary dilation, with collection of round cells scattered through its (the corium’s) structure, particularly around the hair follicles.” There is, therefore, little suggestive of the explanation of the effects of x-rays, upon diseased conditions of the connective tissue structures of the skin, in the histology of x-ray dermatitis, as far as it has been studied. An analysis of the clinical phenomena does, however, throw some light on the subject. Tn the first place, as regards the hair follicles, Kibbe has made the interesting observation, which I am able to confirm as regards x-ray erythem.as, that in the development of an x-ray dermatitis the erythema is seen, under a hand lens, to develop first as a “punctate redness due to hyperemia around the hair follicles.” In sycosis under treatment with x-rays, inflammation first shows around the hair-follicles and, I may add, if the exposures are rightly managed, the inflammation may be confirmed to the perifollicular tissue. In other words, the hair follicles and their connective tissue envelopes are particularly sensitive and react first to the irritation of x-rays. This is more than ever the case if the follicles are already the seat of disease. To this extent, and to this extent only, x-rays may be said to have a selective action on the hair follicles in inflammatory affections, like sycosis and tinea tonsurans.
Much the same may be said in regard to its effect in lupus. If a patch of lupus is put under the influence of x-ray exposures the lupus nodules become reddened and inflamed before, or even without the surrounding healthy tissues being affected at any time. Foci of disease so small as to be imperceptible before treatment become inflamed, redden up, and become visible. If the exposures are persisted in, the lupus nodules will break down and be destroyed before the surrounding tissue is severely affected. Tn other words, the specific tissue of the lupus nodules is of such low vitality that the influence of x-rays may cause its absorption or even destruction before having any considerable effect upon healthy tissue. And thus far the rays may be said to have a selective action on lupus.
The interesting question of the bactericidal effects of the rays arises in connection with these bacterial diseases which respond favorably to x-ray exposures. Unfortunately, the knowledge upon this subject is not sufficient to allow positive statement at present. Reports of different observers upon the effects of x-rays on various bacteria do not agree. On the retarding or destructive influence of x-rays on tubercle bacilli there is weighty influence. (Lortet and Geroud, Fiorenti and Luraschi, Ravillet, Aliihsam, Rieder. ) There is also considerable evidence to show the retarding or destructive influence of x-rays on other bacteria. But, on the whole, the reports on this subject are conflicting and do not allow of satisfactory conclusions. It is possible that the explanation of the favorable influence of x-rays on bacterial diseases lies not in the direct destructive influence of the rays on the bacteria, but in the stimulation of the tissues it causes, placing the cells in a condition in which they are better able to cope with the organisms. As an explanation of the favorable influence which the rays have on inflammatory infiltrations as well as on new growths, Kaposi suggests that ”the cellular elements are altered in their structure and are thus made ready for absorption.”
What is the essential factor in x-rays that produces the effects on tissues? It would take us too far from our present topic to undertake here a thorough consideration of this subject. I believe the best opinion has come around to the view that it is something in the rays themselves and not some incident of their production, as has been suggested, like ozone or brush discharges or induced electrical currents in the tissues or particles of platinum carried oft* from the anticathode. As Professor Elihu Thomson expresses it in discussing some experiments on this point : “There is only the supposition left that tlie effect was produced by Rontgen rays or something that comes with the rays.” The lesser degrees of x-ray burns resemble sunburns more closely than any other pathological process, and there seems to be no good reason for not believing that the effects of x-rays on the tissues are due to the actinic rays of the x-rays just as sunburn is due to the actinic rays of sunlight. That certain of the x-rays are strikingly similar in their actinic properties to the rays of light at the violet end of the spectrum is shown by their similar effect on photographic plates. And it is no violence to the reason to suppose that the same actinic properties of the x-rays that cause rearrangement of molecules and the formation of new salts on photographic plates can exercise a similar power on the molecular arrangement of tissue cells and influence their metabolism. The x-rays in their actinic properties are in many respects strikingly similar to the ultraviolet rays of white light. If they are not identical, they at least bear important properties in common, in the effects which they have on chemical compounds and on tissues.
The practical problem which has -to be solved in applying x-rays to the treatment of skin diseases is to so manage the rays as to attain effects sufficient for therapeutic purposes, without overstepping the limits of safety and producing undesirable results. This problem is easier now than it would have appeared three years ago. Space forbids, and it is not necessary, to go into full consideration here of the factors in the production of x-rays which influence the effects on tissues. As is well known, these factors have chiefly to do with the amperage and voltage of the primary current, the capacity of the coil, the “hardness'” of the tube, the rapidity of interruption of the current, the distance from the tube to the exposed surface, and the length of exposure. For the treatment of skin diseases Schiff and Freund have worked these factors out carefully. The conditions to be avoided are, using Freund’s words as nearly as possible :
(a) Too great strength of primary current: One never uses a current of more than one and one-half amperes and twelve volts’ strength. This is. of course, a current much weaker than the currents used for skiagraphy. The currents of high amperage which are used in skiagraphy are not used in work of this sort at all.
(h) Too great tension of secondary current: One never uses an inductor of more than thirty cm. spark length.
(f ) Too long and too frequent exposures.
(d) Not sufficient distance between skin and tube.
At the beginning the sittings are not longer than five minutes and the distance of the tube not less than fifteen cm.
Freund recommends, for the attainment of the best results, the use of a mechanical interrupter run at the rate of eight hundred to one thousand interruptions per minute.
The apparatus required in order to thus accurately apply tiie method
is as follows :
Inductor of thirty cm. spark length, capable of being worked with a current of twelve volts and one and one-half amperes.
Storage battery for the primary current.
Amperemeter and voltmeter for the primary current, and of course suitable rheostats and switches.
Mechanical interrupter with tachometer for measuring the number of interruptions.
Suitable lead masks for protecting surfaces which arc contiguous to the areas to be treated.
Undcr the conditions of treatment laid down above and with apparatus of this sort, Freund assured me that in the treatment of a large number of cases he had never had any undesirable results; never any injury amounting to more than a slight dermatitis.
Another factor — probably the most important one — which has to be taken into consideration is on the side of the patient, vis., personal idiosyncrasy. It is probable that in all the severer x-ray injuries the most important factor has been idiosyncrasy. This factor may be excluded, as suggested by Freund, by making three exposures and leaving off further treatment for three weeks, to see if any effects result. If they occur from so slight exposure the case is not suitable for this treatment.
The evidences that the exposures have been carried far enough are :
I. The appearance of erythema or pigmentation.
II. Blanching of the hair.
III. Loosening of the hair.
In the treatment of hypertrichosis the method is pursued with great caution to avoid irritation. In the treatment of inflammatory affections less care is taken. It is aimed to produce a slight degree of inflammatory reaction, and to so regulate the exposure as to hold irritation at this stage.
It is not found necessary in the treatment of any of the diseases to carry the irritation to a painful degree.
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