BY WILLIAM F. BREAKEY, M. D., ANN ARbor, Michigan.

LECTURER ON DERMATOLOGY AND SYPHILOLOGY IN THE UNIVERSITY OF MICHIGAN.

[PUBLISHED IN The Physician and Surgeon EXCLUSIVELY]

PHOTOTHERAPY so-called, devised by DOCTOR NEILS FINSEN, of Copenhagen, is a system of applying sunlight in the treatment of diseases of the skin-particularly in lupus, the rodent ulcer form of epithelioma, and some other affections-which he believes more effective than Roentgen rays.

The use of light in the treatment of disease is not wholly new, though the method and technique are quite different from the simple sun baths behind blue glass windows first-in this country at least I think-brought into prominent notice thirty years ago or more by GENERAL PLEASANTON, a famous cavalry commander during the civil war. The application of the treatment was not limited to tuberculous disease.

We all know the effects of light and shade on plant life as well as on animal life. The woodman finds his way, in the absence of compass when the sun cannot be seen, by the lichen moss on the shady side of trees. Most of the outdoor plans of treatment include sunlight. It is neither unscientific nor unreasonable that the sun, the popular source of light and heat and power, should also have healing in its rays or that its transmuted electric beams should have the same miraculous effect. These might have been among the "more things in heaven and earth than were dreamed of in the philosophy of Horatius." This naturally follows the X-ray in the treatment of diseases of the skin. This beautiful conception of faith in the provision in the great alchemy of nature to cure the ills of life is more rational than many others with which the credulous, sanguine

patient often diverts himself, while he gets well either under intelligent treatment-sanitary, hygienic, or medicinal, or dies from irremedial causes. A year ago a department was organized in the London Hospital for the treatment of lupus and other diseases of the skin by the methods of PROFESSOR FINSEN, the apparatus used being substantially the same as that employed by the Danish professor. Sun or electric light is passed through hollow lenses containing solutions which absorb the caloric rays. The ultra violet or chemical rays are focussed on the affected part which is rendered anemic by pressure by glass compress. These rays have been shown to have considerable bactericidal power. The skin is cleansed, the diseased area outlined and covered by a piece of moist lint, with a hole corresponding to the extent of surface to be treated at one time-about three-fifths of an inch in diameter. The duration of the treatment varies, averaging about an hour. The parts are then dressed with carbolized zinc ointment. There is no immediate redness, swelling, or pain, but after from six to twelve hours redness and swelling occur, and after twentyfour hours bullæ often form and serous oozing but rarely pustulation occurs. If the area is large the periphery is first attacked with a circle of rings carried concentrically inward. The tubercle bacilli are destroyed but the healthy skin is not injured. The treatment may need to be repeated daily for months.

FINSEN has also treated alopecia with the chemical rays of light and obtained good results. The report does not indicate whether alopecia was due to parasitic origin. Conversely DOCTOR WILLIAM ALlen Pusey, who has done much creditable work with X-rays in the treatment of various diseases of the skin, and has published various contributions to the literature of the subject, following the investigations of FREUND and SCHIFF in the use of X-rays for the removal of superfluous hair based on the facts previously shown by BERTHELMY and DARIEN, states that the X-rays tended to produce atrophy of epithelial tissues. DOCTOR PUSEY also states as his belief-an opinion I have heretofore expressed-that the active rays among the X-rays if not identical are at least so similar in all their properties as to be practically identical with the rays at and beyond the violet end of the spectrum and if this is true this method of treatment by the X-ray--is identical in principal with that of FINSEN.

DOCTORS MALCOLM MORRIS and S. ERNEST DORE report their experience with the light treatment in lupus and rodent ulcer, giving some further details of technique in the use of the electric light. A current of seventy-five amperes and sixty volts is usually sufficient. The crusts if any should be removed, the parts cleansed with boric acid or other antiseptic solution-ether if the surface is greasy, and the part to be treated marked with a blue pencil. The lenses must be clean and bright and the water free from floating particles. The rays should fall perpendicularly on the compressing glass, which should be held in place by elastic bands.

The resulting reaction varies somewhat with the idiosyncrasy of the patient. The time of its appearance varies from five to twenty-four hours. It is usually slight at first becoming more marked later, and the duration of the sore from primary hyperemia to complete healing is from ten days to a fortnight. When situated over loose tissue, as the eyelids, there may be considerable swelling from the treatment. Lupus vulgaris is the disease most amenable. In some cases one application is sufficient to cause the disappearance of a small isolated superficial nodule. Generally in cases in which extensive area is covered a new spot is treated each day, and the parts first treated are sufficiently healed in a few days to have treatment repeated. In cases in which there is extensive disease the treatment may have to be continued a year or more. When there is much thickening of the skin pyrogallic acid ointment quickens the action. In rodent ulcer the healing often follows quickly after the application. In lupus erythematosus the effects have been marked though not so certain as in lupus vulgaris. Constitutional effects are practically nil. The unfavorable conditions are those which hinder the penetration of light, such as scarring, pigmentation, great vascularity, great depth of the disease below the surface, and the situation of the disease in a position to make the application difficult or inaccessible. In very extensive disease the condition is unfavorable both on account of the long duration of treatment and the possibility of its spreading in one direction while another is being treated. Cases are favorable when the disease is limited, not spreading, and has undergone no previous treatment. The advantages of the method are reliability, painlessness, excellent cosmetic results, less liability to relapse, and avoidance of surgery. The disadvantages are the small area treated at one time, long time required, and the expense.

FINSEN discusses the subject in a report from his institute reaching the following conclusions:

(1) I have confirmed the results of MEDMARK's researches on the action of light upon the skin, and further proved that the visible chemical rays. have also the power to produce specific photochemical inflammation of the skin.

(2) I have shown that in the electric light the strongest bactericidal power resides in the ultra violet rays and as a practical conclusion it follows that quartz lenses ought exclusively to be used in electric light concentrating apparatus; and this alteration (from glass lenses) has immensely advanced the treatment with concentrated light.

(3) I have pointed out that the dilatation of cutaneous vessels produced by the chemical (ultra violet) rays is of considerable duration, and it has even been possible to show this about half a year after the light's action, (4) Comparison of the different factors acting on the skin has shown that the normal reddish color which the skin acquires when uncovered seems if not exclusively certainly for the most part to be produced by the

chemical rays; its occurrence seems to be retarded by heat and promoted by cold.

FINSEN thinks that not only the pigmentation, but the chronic redness of the skin, indicating an abundant blood supply to the skin following are among the chief results of the light and that we are entitled to presume that the skin is better nourished and more able to perform its functions— though he admits we do not know what these functions are-and not until we have a definite knowledge of these functions will the importance and value of the action of light on the skin be clear. He states that: "At the Light Institute we have for some time past, but principally with other objects in view, tried the therapeutic use of photochemical light baths (sun baths, electric light baths). Our experience has, however, been very limited up to the present time, and we are not yet out of the experimental stage. This very conservative summary of his investigations will impress the reader with his sincerity. Whether curative effects are due to the bactericidal power of rays, or to improved nutrition of the skin, or to both is still an open question. It will be noticed, however, especially in the report of the clinical trials by MORRIS and DORE, that the cases in which the light treatinent was most successful, were the separate small shallow lesions of recent formation, precisely the kind of lesion that is so satisfactorily treated in lupus by curetting and cauterization, or in epitheliomata by the same means or by excision. The method of treatment while interesting and curious has not been sufficiently tested as yet, and especially in cases not amenable to other satisfactory plans of treatment. hoped that further trial and investigation will not only make clearer its therapeutic action but also demonstrate its applicability to a wider range of cases, with greater simplicity, less expense, and perhaps less time. The profession will await with much interest further investigation and developments, hoping that the action of the actinic light rays will prove a valuable addition to the treatment of diseases of the skin.

It is to be

Since this paper was written many interesting contributions to the "light treatment" have been made, among them a valuable article by DOCTOR AUGUST RAVOGLI of Cincinnati. Various modifications of Finsen's apparatus have been introduced, and there is danger that the method may suffer disparagement by efforts of inexperienced operators, imperfect apparatus, and attempts to apply the treatment to inappropriate cases. One of the best outfits for the treatment (and one which has received the commendation of RAVOGLI and other eminent dermatologists) is manufactured at Lyons, France. Numerous cases of lupus, superficial epithelioma and some other forms of superficial disease have been treated with varying success in the skin clinic at the University Hospital during the past three or four years. A large flat keloid treated within a year showed marked improvement. It is expected that the Lyons apparatus will soon. be added to the present equipment in the hospital.

A STUDY IN OBSTETRICS.*

BY JAMES E. DAVIS, M. D., PH. G., DETROIT, MICHIGAN.

MEMBER AMERICAN MEDICAL ASSOCIATION; PRESIDENT ALUMNI ASSOCIATION DETROIT COLLEGE OF MEDICINE, ET CETERA.

PUBLISHED IN The Physician and Surgeon EXCLUSIVELY]

TARNIER writes, in his preface to the sixth French edition of "Theory and Practice of Obstetrics," by CAZEAUX and TARNIER, issued 1886: "A classical book soon grows old in these days... by the progress of science."

A cursory comparison of the most recent text-books upon obstetrics with those issued a half century ago is sufficient to reveal the fact that, excepting anesthesia, asepsis and antisepsis, midwifery has made but little progress. It would seem that midwifery has yielded to her sister, gynecology, a large measure of her popularity. The accoucheur possessing a national reputation gained without aid from his gynecologic work is, indeed, rare at the beginning of the twentieth century. Yet, withal, midwifery is, perhaps, more advanced toward scientific perfection than any other branch of medicine. There is no department of medicine that answers more truly to the technical definition of a science than does obstetrics. Its mathematical and mechanical essentials are ever present in the estimation of the forces of expulsion and resistance.

The chemistry of asepsis and antisepsis as demonstrated by SEMMELWEIS, LISTER and others, must be known and practiced. The therapeutic agents employed in midwifery are those of definite physiologic action, consisting usually of an anesthetic, vasomotor stimulant, antiseptic and oxytocic.

Obstetric work can be at the same time the most exacting and the most indifferent of work. If the forces of expulsion and resistance are equal, or resistance greater than expulsion, the obstetrician is brought face to face with conditions which will command skill, ingenuity and courage. If nature is able to accomplish her work unaided, the medical attendant is little more than a spectator who will require remuneration only for his time and good judgment, his chief responsibility being that of noninterference.

The principles of asepsis and antisepsis are never more valuable than in the practice of obstetrics, when upwards of ten per cent. of all women confined can be saved from death by sepsis if rigid asepsis is observed.

A case of labor commands of its attendant, first, intelligent assistance; second, intelligent noninterference; third, rigid asepsis. The intent of this essay is to deal with some features in the physiology and management of labor.

The interest of a physician in any particular line of work is commensurate with his success therein, but there are always essentials which pre

*Read before the DETROIT MEDICAL SOCIETY.