General.

    A systematic treatment of radiation physics would be beyond the scope of this book.  It is assumed that the reader has a general understanding of such matters as the theory of electro-magnetic vibrations, the transformation of these vibrations into other forms of energy when they are absorbed, and the common units of measurements used in electrical work.  A short list of recent books and papers is given which will assist further reading in these subjects in connection with light therapy.
 
Units and Constants.

    The following data are stated for reference:

    Spectrum wave-lengths:
 

1       A. U. (Angstrom Unit)	=1 mm./10,000,000	(10-7 millimetre).
1   uu (millimicron)	=  1 u/1,000	(10-6 millimetre).
1   u (micron)	=  1 mm./1,000	(10-3 millimetre).

 
    The unit commonly used in Britain is the A.U.

    Speed of Transmission:  (Velocity of light, uniform for all electro-magnetic vibraitons) = 300,000 kilometres per second.

    Electrical units:

    Volt = Unit of electro-motive force (i.e., that pressure which will cause a current of 1 ampere to flow against a resistance of 1 ohm.
    Ampere = Unit of rate of transfer of electricity.
    Watt = Unit of quantity of electricity transferred, i.e., the amount of current consumed when a current of 1 ampere flows at a pressure of 1 volt.
    Ohm = Unit of resistance to electric flow, i.e., the resistance of a column of mercury 106.245 cm. long X 1 mm. diameter at 0 degrees C.
 
Radiations used in Actinotherapy.

    The groups of electro-magnetic vibrations used in actinotherapy are:
 

    A certain aspect of radiation physics which has special significance for the practitioner of actinotherapy is considered in outline here, i.e., the output of different sources in the various spectrum regions.  The spectrum photograph of any source gives merely a qualitative indication of its emitted energy.  It is necessary to know also how the total energy radiated is divided between the different parts of the spectrum.  To determine this accurately requires the resources of a specially equipped physical laboratory.  For practical use in actinotherapy the problem narrows down to estimating dosage in terms of biological reactions to certain short wave-lengths.  This makes it practicable to estimate the output of a source either by physical methods (spectroscopy, photolytic measurement) or by biological estimation (erythema reaction, bactericidal effects, etc.).  A classified list of recent publications on the subject will be found on page 15 (8-33).
    The energy distribution of the quartz mercury arc and other standard sources used in therapy are well established, and the user can rely on approximately constant energy distribution, provided that lamps are operated to instructions.  Most users find it sufficient to standardize their lamps by occasional erythema lists on a standard subject, or by a simple gauge such as the actinometers specifically designed for use with quartz lamps.
 
 
Output Characteristics of Standard Lamps.
 
    For effective use in actinotherapy, a source must generate adequate total radiation.  Further, a sufficient proportion of this total must be generated in the required section of the spectrum.  For the standard sources discussed in this book, the output characteristics are:
 

	Ultra-violet.	Visible.	Infra-red.
Sollux Lamp (9)	0.2%	7.6%	92.2%
Quartz Mercury Arc  air-cooled   (41   43a).	28%	20%	52%

 
    With the Kromayer Lamps, as water-cooling reduces the proportion of infra-red output, the percentages of visible and ultra-violet radiation are considerably higher (34).

(See output diagram, page 18.)

    The distribution characteristics of a quartz burner are practically constant throughout its operating life.  An aged burner shows decrease in total output, which affects both the short and long ultra-violet and the visible spectrum in a nearly equal measure (Anderson).  A list of recent technical papers on the mercury vapour arc will be found on page 16 (34-43a).
 
Filters and Screens.

    The human eye is very sensitive to the short ultra-violet rays below 3150 A.U. It is essential to use goggles which completely protect the eyeball, or efficient screens, when using ultra-violet sources. Most commercial glasses, in adequate thickness, are opaque to the irritant rays, and therefore safe as screens.

Filters.

    In certain therapeutic and other applications, the need arises for filters which will transmit certain portions of the spectrum. Following are transmission data for the filters mentioned in this book:--
 
 

Filter.	Uses.	Spectrum Limits (A.U.)
		Short.	Long.
"Diagnosis"	Fluorescence (excluding visible light).	3000 --	4000
		maximum at 3660
"Uviol White"  (2 mm.)	Exclusion of shortest ultra-violet rays.	2600 --
"Uviol Blue"  (2 mm.)	Exclusion of shortest ultra-violet rays.	2750 --	5000
		(6550 -- 30,000)
Sollux Red  (2mm.)	Red and infra-red radiation.	6000 --
Sollux Blue  (2mm.)	Blue and infra-red radiation.	3010 --	4550

 
 
REFERENCES TO LITERATURE.

Physics in General.

    1. Harris, D.T. -- Technique of Ultra-violet Radiology (19332 6/-).
    2. Luckeish, M. -- Ultra-violet radiation, its properties, production, measurement and applications (1923, 21/-).
    3. Anderson, W.T. -- Quartz Lamp, August, 1923 -- March 1924.
    4. Goodman, H. -- Trans. Illum. Eng. Soc. (N.Y.), April, 1927.
    5. Hauer, F. -- Die kunstlichen Lichtquellen (in Handbuch der Lichttherpie, ed. Hausmann & Volk), 1927.
    6. Hopwood, F.L -- Nature, April 21st, 1928.
    7. Hibben, J.H. -- Med. Jnl. and Record, April 1st, 1931.
        Also Nos. 785     787     790     792

Determination of Actinic Output.

General.

    8. Baly, E. C. C. -- Spectroscopy, Vols. 1-2 (1924-1927.).
    9. Ryde, J. E. -- Elec. Rev., June 5th, 1925.
    9a Nogier, T. -- Phys. Therapeutics, October, 1926.
    10. Finkenrath, K. -- Zentrablatt F. Haut-Krankheiten, 1927, 15, No. 7.  (Contain a summary of papers prior to 1924.)
    11. Halban, H. & Eisenbrand, J. -- Proc. Royal Society, A., 116, 1927, 153-160.
    12. Estey, R. S. -- Med. Jnl. and Record, December 17th, 1930. (See also list of works under Dosage, Nos. 141 to 152.)

Photometric Measurement.

    13. Anderson, W. T. & Gordon, E. -- Jnl. Optical Soc. America, March 1928.

Photo-Chemical Measurement.

    14. Bering, F. & Meyer, H. -- Strahlentherapie, 1912, No. 1-2.
    15. Keller, P. -- Klin. Ws., 1924, No. 37.
    16. Webster, A., Hill, L. & Eidinow, A. -- Lancet, 1924, l, 745.
    17. Anderson, W. T. & Robinson, F. W. -- Jnl. Amer. Chem. Soc., March, 1925.
    18. Pohle, E. A. -- Jnl. A.M.A., March 20th, 1926.
    19. Moss, J. E. & Knapp, A. W. -- Brit. Jnl. Actinotherapy, January 1927.
    20. Gillam, A. E. & Morton, R. A. -- Jnl. Soc. Chem. Industry, 46, 1927, No. 44.
    21. Hauer, F. -- Methoden der Lichtmessung im Ultraviolett (in Handbuch der Lichttherapie, ed. Hausmann & Volk, 1927).
    22. Morton, R. A. -- Radiation in Chemistry (12928, 12/6), Chapters 3, 6.

Photo-Electric Measurement.

    23. Dorno, C. -- Strahlentherapie, 14, 1922, No. 1.
    24. Peemoller, F. & Dannmeyer, F. -- Med. Klinik, 1923, No. 29.
    25. Griffith, H. D. & Taylor, J. S. -- Lancet, December 5th, 1925.
    26. Dannmeyer, F. -- Strahlentherapie, 22, 1926, 738-750.
    27. Ruttenauer, A. -- Strahlentherapie, 27, 1928, 794-799.
    28. Harris, D. T. -- Jnl, Sci. Instruments, January, 1929.
    29. Goodman, H. -- Phys. Therapeutics, February 1929.

Biological Estimation.

    30. Coblentz, W. W. -- Amer. Jnl. Electrotherapeutics, July, 1925.
    31. Peacock, P. R. -- Lancet, August 22nd, 1925.
    32. Bridge, E. -- Med. Jnl. and Record, December 4th, 1929.
    33. Waller, M.D. -- Proc. Royal Society, B., 108, 1931, 264-270 (Quartz Lamp, S., October, 1931).

The Mercury Vapour Arc.

    34. Johannsen -- Strahlentherapie, 1915, 45.
    34a. Coblentz, W. W. -- Amer. Jnl. Electrotherapeutics, October, 1921.
    35. Watters, B. D. H. -- Phil. Mag., September, 1924.
    36. Coblentz, W. W. -- Amer. Jnl. Electrotherapeutics, December, 1925.
    37. Reeve, L. -- Jnl. Phys. Chemistry, January, 1925.
    38. Drane, H. D. H. -- Brit. Jnl. Actinotherapy, June, 1926.
    39. Gillam, A. E. & Morton, R. A. -- Phil. Mag., December, 1928.
    40. Coblentz, W. W. -- Jnl. Amer. Med. Ass., June 1st, 1929.
    41. Anderson, W. T. -- Radiology, July, 1930 (Quartz Lamp, S., October, 1931).
    42. Anderson, W. T. -- Med. Jnl. and Record, December 17th, 1930 (Quartz Lamp, January 1931).
    43. Dingee, A. L. M. -- Phys. Therapeutics, May, 1930.
    44. McAlister, E. D. -- Absolute intensities in the visible and ultra-violet spectrum of a quartz mercury are (Smithsonian Institution, 1933).

Filters and Screens.

    44. Watters, F. D. H. -- Lancet, September 5th, 1925.
    45. Goodman, H. & Anderson, W. T. -- Boston Med. and Surg. Jnl., January 12th, 1928 (Quartz Lamp, February, 1928).
    46. Watters, B. D. H. -- Brit. Jnl. Actinotherapy, August, 1929.
    47. Coblentz, W. W. -- Journ. A.M.A., Sept. 20th, 1930 (Quartz Lamp, December, 1930).
    48. Ross-Mansell, J. -- Optician, May 8th, 1931.
    49. Grant, J. -- Glass, September, 1932.
        Also Nos. 2 783
 

Penetration of the Skin.

    Penetration is an important factor. When the skin is dehaematized by compression, penetration may be increased; otherwise, all rays shorter than 3000 A.U. are absorbed by 1 mm. thickness of skin. The longer ultra-violet rays (over 3000 A.U.) have somewhat greater penetration, but are all absorbed between the stratum corneum and the dermis.

Rost (132) states the absorption of ultra-violet rays in the various skin strata:
 

S. corneum	---	some fluorescence.
S. lucidum	---	little action observed.
S. granulosum	---	little action observed.
S. germinativum	---	absorption: reaction (pigment formation).
Papillae	---	endothelial absorption: vascular enlargement: erythema.
Corium	---	direct absorption by capillaries (assumed but not demonstrated).

 
    The visible rays increase in penetration as they increase in wave-length (64). Of the radiations used in actinotherapy, the visible red rays (to which the blood is transparent) and the short infra-red up to 11,000 A.U. have the greatest penetration (see diagram, page 18).
    In the infra-red region, penetration diminishes with increasing wave-length. Rays longer than 15,000 A.U. are totally absorbed in 3 mm. of skin. The most effective sources to produce deep penetrating hyperaemia are therefore those with a large output of visible light and of the shortest infra-red rays. The subject has been well investigated in recent years--a list of important papers is given on page 27.

Effects on the Skin.

    The local reaction of the skin to actinic rays is the latent erythema which develops after a few hours. The latent period varies inversely with the exposure (63 81) and may range from 1 to 8 hours. The erythema is not a primary but a secondary reaction, associated with increase of temperature and emission of heat by the skin.
    The wave-lengths most active in producing erythema are those below 3200, with maxima about 2970 and 2500 A.U. (see the diagram on page 18).
    The erythema reaches its maximum 8 to 24 hours after exposure, and then subsides. A mild erythema (first degree) may practically disappear within 24 hours. There are great individual variations in the onset, peak, and total duration of erythema reactions; Schall and Alius have studied these in detail (68 69 76).
    Histologically, the erythema is associated with enlargement of the capillary vessels, which are filled with erythrocytes, and with leucocytosis in the irradiated area. The inflammatory reaction is not confined to the irradiated surface, but extends deeply into the tissues.
    In relatively few conditions (ulcers, wounds, dermatomycoses) is the direct bactericidal action of light exercised on the human body. Actinic irradiation takes effect primarily on the skin functions, which in time set up secondary reactions in the organism as a whole.
    Memmesheimer (77) explains the process as follows: -- The skin is conceived as a gland with internal secretions, which are of importance in the defensive mechanism of the body ("esophylaxis"). Under the stimulus of actinic rays the walls of the skin-cells in the absorbed layers become permeable, and substances pass from the activated cells outward into the blood. These substances (the so-called "detoxin") consist of tyrosin and other amino-acids. They promote increase of antibodies in the blood.
    Other substances transmitted from the irradiated skin-cells into the blood resemble histamine in their action.
    Very powerful local erythema (dermatitis bullosa) releases products of inflammation from the cells which have the same effect as parenteral proteins (831).
    Pronounced erythema is followed by desquamation. A severe (fourth degree) erythema will produce blisters, due to exudation of leucocytes between the horny and granular layers of the epidermis; these heal without scars.
    Pigmentation is due to the production of oxydase ferment ("dopa") by the skin cells during the regenerative phase which succeeds their first response to light stimulus. This ferment leads to the formation of melanin caps on the epithelial and basal cells of the epidermis. Pigmentation and erythema, although often associated, are not inter-dependent; pigmentation is produced by longer-waved radiations than the erythema-causing band. The function of pigment is disputed; Rost (132) and other authorities assert that repetition of the erythema reaction, avoiding pigmentation, produces best results. References 65 77 (page 28) show the most important recent publications on this aspect.

Fluorescence.

    For a detailed summary of the use of fluorescent rays in the examination of blood, urine, bile, and of internal organs, the work of Radley & Grant (88) should be consulted.
    In medicine, the chief application of fluorescence has been in the field of dermatological diagnosis. The detection of ringworm by its vivid green fluorescence is now routine procedure (see references under Tinea, Nos. 641 to 650). Many other skin diseases also show characteristic fluorescences which are valuable aids in diagnosis.
    Goodman (85) gives a useful list of characteristic fluorescences from which the following are extracted:--

    Keratosis -- white underlying fluorescence.
    Leucoderma -- white in vivid contrast to surrounding skin.
    Pityriasis versicolor (microsporon furfur) -- dull golden yellow glow.
    X-ray dermatitis -- marked fluorescence in patches, dark elsewhere.

    Other authorities mention favus, impetigo, psoriasis (which gives a silvery appearance), as readily diagnosed by their fluorescence.
    Anomalies such as eczematous changes and incipient X-ray dermatitis can be detected by fluorescence at a stage when they are invisible by ordinary illumination. Changes in teeth, hair, and other structures are more visible under the invisible rays than in daylight.

Effects on the Blood.

    Experiments and clinical findings indicate that actinic radiation produces considerable changes, most probably indirect, on the blood and haemotaopoietic organs. Although there is some discordance in the recorded results, probably due to the different light sources utilized and to variations in the subjects, it is clearly established that blood-regeneration in anaemic conditions takes place more rapidly under irradiation than in its absence. The characteristic changes in the blood picture are probably developed by way of the sympathetic nervous system (595).
    There is marked action on the white blood cells. The erythema-producing rays produce leucocytosis and lymphocytosis, with a shift in the differential leucocyte court (increase in polymorph cells). The maximum change occurs about 4-5 hours after irradiation; there is usually a return to normal within 4-5 days. The red cell count and haemoglobin content show increase after irradiation, particularly when sub-normal at the outset.
    The erythema-producing rays, in normal dosage, evoke a rise in the bactericidal power of the blood. (It is stated that over-dosage may reverse this effect) (92). Probably associated with this factor is the increased resistance to infection of various kinds, e.g., staphylococcus (106), colds (273), diphtheria (91), which follows actinic irradiation. Huntermuller (109) has measured a three-fold increase in the alexines after light baths.
    Other recorded changes in the blood picture after irradiation include: -- Reduction in alkalinity (96); shortening of bleeding time (102); increase in serum mineral content (calcium, phosphorus, iron, iodine); decrease in blood sugar.
    Associated with the vascular dilation is a reduction of high blood pressure, often considerable in extent (796).
    It cannot be said that the important subject of blood reactions is yet satisfactorily understood. References 89-112 (page 29) will assist further reading.

Effects on Metabolism.

    Actinic irradiation with the short ultra-violet rays (below 3020 A.U.) creates Vitamin D in the human body, raises the serum content of calcium and phosphorus, and promotes the fixation of these minerals in the body. It is thus of special value in conditions of calcium deficiency (rickets, tetany, osteomalacia) and during times of abnormal calcium demand (e.g. pregnancy).
    Irradiation produces other changes in metabolism, likewise important in their results but less well explained. Some are probably indirect effects of exposure to light, conditioned through the sympathetic nervous system. There is considerable discordance between different observers' reports, due probably to inevitable differences in subjects, sources, intensity of exposures, and other variables.
    Respiration is decreased in frequency and increased in depth, with a net rise in minute-volume. Intake of oxygen and output of CO2 show increase.
    Both anabolism and catabolism appear to undergo stimulation through light. This leads in practice to the paradox that irradiation will both reduce obese and develop thin subjects.
    Irradiation has also considerable effects on the carbohydrate metabolism. There is increase both in mobilisation and combustion of blood sugar, and parallel to this proceeds a reduction both of glycosuria and of acetone body excretion in diabetic subjects.
    For some days following a general light bath, there is considerable increase in excretion of nitrogen, phosphorus, sulphur and salt, indicating enhanced activity in albumen metabolism. Many reports indicate increased fixation of iron after irradiation, and the iodine content of the thyroid also shows some rise.
    Ultra-violet radiation has a stimulating and regulating effect on the endocrine glands, and assists the production of hormones. Thus, the effects of endocrine therapy are increased by concurrent irradiation.

General.

    Among the physiological effects of irradiation should also be mentioned its effects on the nervous system. It acts on the sympathetic system, and so affects the respiration and the endocrine glands. Again, it has marked analgesic effects, probably due to action of the rays on the peripheral nerve terminals.
    The following summary of physiological reactions is given for reference:--

(a) Direct Effects.

    Direct bactericidal action on surface infections.
    Stimulus of skin cells and increase in their oxygen-metabolism.
    Release of endogenous proteins and other substances into circulation (after severe dose).
    Formation of vitamins or pro-vitamins.
    Erythema, some hours after irradiation, with dilation of the superficial blood vessels, increase in skin temperature and vasomotor activity. Erythema is not usually observed in infants.
    Improvement of skin tone, and increased firmness and development of the underlying musculature. Increased "esophylaxis" (anti-body forming function of the skin).
    Stimulation of the skin functions (transpiration, heat regulation, resistance to infection).
    Pigmentation (after a series of increasing exposures).

(b) Effects on the Blood through the Skin.

    Increased content of calcium, phosphorus, iron and iodine.
    Increase in the bactericidal power (originating locally in irradiated area).
    Increase in haemoglobin and red corpuscles.
    Lymphocytosis and leucocytosis.
    Normalization of blood pressure.

(c) General Effects on the Body.

    Increased metabolism, shown in improved appetite and sleep, increased assimilaton and diuresis.
    Marked mental stimulation, through action on the central nervous system.
    Reduction of pain through analgesic effect on the peripheral nervous system.
    Deepening and slowing of respiration, with increased expiration of carbon dioxide.

REFERENCES TO LITERATURE.

Penetration.

    50. Macht, D. I., et al. -- Proc. Soc. Exper. Biology, 1925, 23, No. 5 (Quartz Lamp, February, 1926).
    51. Schultze, W. & Rothmann, S. -- Strahlentherapie, 1926, 22, p. 736.
    52. Stenstrom, W. & Reinhard, M. -- Acta Radiologica, 1926, 5, p. 552 (Brit. Jnl. Actinotherapy, April 1927).
    53. Reis, J. v. -- Schweiz. Med. Ws., March 12th, 1927, p 248.
    54. Anderson, W. T. & Macht, D. I. -- Amer. Jnl. Physiology, September, 1928, and Brit. Jnl. Actinotherapy, October, 1928.
    55. Macht, D. I., Anderson, W. T. & Bell, F. K. -- Jnl. A.M.A., January 21st, 1928.
    56. Bachem, A. & Kunz, J. -- Archives Phys. Therapy, February, 1929.
    57. Bachem, A. & Reed, C. I. -- Amer. Jnl. Physiology, November, 1929 (Quartz Lamp, N., July, 1931).
    58. Bachem, A. -- Amer. Jnl. Physiology, December, 1929 (Quartz Lamp, N., September, 1931).
    59. Hill, L. -- Med. Press, June 11th, 18, 1930 (Quartz Lamp, S., October, 1931).
    60. Takahashi, T. -- Brit. Jnl. Phys. Med., July and August, 1930.
    61. Anderson, W. T. & Fraser, H. D. -- Brit. Jnl. Phys. Med., November 1931.
    62. Bachem, A. & Reed, C. I. -- Amer. Jnl. Physiology, April, 1931 (Quartz Lamp, N., June 1931).
    63. Lucas, N.S. -- Biochem. Jnl., 25, 1931, No. 1.
    64. Pearson, A. R. & Gair, C. J. D. -- Brit. Jnl. Phys. Med., May 1931.
    Also Nos. 132     177

Skin Effects.

    65. Hausser, K. W. & Vahle, W. -- Strahlentherapie, 1922, 13, 41-71.
    66. Hausmann, W. -- Strahlentherapie, 1923, Suppl. 8, p. 126 (Quartz Lamp, February, 1924).
    67. Moncorps, C. -- Munch. Med. Ws., 1924, No. 30.
    68. Schall, L. & Alius, H.J. -- Strahlentherapie, 19, 1925.
    69. Schall, L. & Alius, H. J. -- Strahlentherapie, 23, 1926, p. 161-180.
    70. Schultze, W. & Rothmann, S. -- Strahlentherapie, 22, 1926, 736-737.
    71. Hausser, K. W. & Vable, W. -- Siemens Wiss, Veroffentl., 6, 1927.
    72. Politzer, G. -- Die morphologischen lichtbewerkten Veranderungen normaler und errankter Gewebe (in Handbuch der Lichttherapie, ed. Hausmann & Volk), 1927.
    73. Bloch, B. -- Iere Conf. Internat. Lumiere, Lausanne, 1928.
    74. Eidinow, A. -- Brit. Jnl. Tuberculosis, July, 1928.
    75. Hausser, K. W. -- Strahlentherapie, 28, 1928, 25-44.
    76. Schall, L. & Alius, H. J. -- Strahlentherapie, 27, 1928, 769-793.
    77. Memmesheimer, A. J. -- 18th Rept. St. John's Hosp. Derm. Soc., 1929.
    78. Rohr, H. O. -- Strahlentherapie, 1929, 34, 157-189.
    79. Smith, M. G. -- Amer. Jnl. Phys. Therapy, January, 1930.
    80. Bachem, A. & Reed C. I. -- Archives Phys. Therapy, October, 1931 (Quartz Lamp, N., November, 1931).
    81. Waller, M. D. -- Proc. R. Soc., B, 1931, 108, 259-263 (Quartz Lamp, S., October 1931).
        Also Nos. 785 (Chap. 7);     796     886

Fluorescence.

    82. Keller, P. -- Derm. Ws., April 3rd, 1926.
    83. Lewin, H. -- Derm. Ws., June 19th, 1926.
    84. Klovekorn, G. H. -- Derm. Zs., 1927, 50, 27-29.
    85. Goodman, H. -- Amer. Jnl. Phys. Therapy, August, 1928.
    86. Woodbury, F. T. -- Phys. Therapeutics, November, 1928.
    87. Kramer, K. -- Virchow's Archiv., 1929, 274, 215-222.
    88. Radley, J. A. & Grant, J. -- Fluorescence Analysis in Ultra-violet Light (1933).
        Also Nos. 131 641-650 829

Blood Effects.

    89. Naswitis, K. -- Med. Klinik, 1922, No. 44.
    90. Ramain, P. -- Recherches sur l'influence des radiations solaires, ultra-violettes et infra-rouges sur le taux des globules blancs et la formule hemoleucocytaire (Montpellire, 1923).
    91. Sonne, C. -- Strahlentherapie, 1923, 16, No. 1.
    92. Colebrook, Eidinow & Hill. -- British Jnl. Experimental Pathology, 5, 1924, 54-64.
    93. McCaskey, D. -- Med. Jnl. & Record, December 17th, 1924.
    94. Davis, F. A. -- Med. Jnl & Record, August 19th, 1925 (Quartz Lamp, July, 1926).
    95. Bannerman, R. G. -- Brit. Jnl. Radiology (B. I. R.), February, 1926.
    96. Gheldere, C. & Roover, M. -- C. R. Soc. de Biologie, March 26th, 1926 (Brit. Med. Jnl., April 1926).
    97. Koeppe, H. -- Strahlentherapie, 1926, 23.
    98. Peemoller, F. & Franke, H. -- Strahlentherapie, 1926, 21, 165.
    99. Tosi, G. -- Raggi Ultravioletti, 1926, 2, 194-213.
    100. Eidinow, A. -- Lancet, November 5th, 1927.
    101. Kennedy, W. P. & Thompson, W. A. R. -- Quarterly Jnl of Experimental Physiology, 1927, 18, 263-266.
    102. Sanford, H. N. -- American Jnl. Dis. Children, January, 1927.
    103. Gonce, J. E. & Kassowitz, K. -- Jnl. A.M.A., January 28th, 1928.
    104. Spence, K. C. -- Brit. Jnl. Actinotherapy, August, 1928.
    105. Spence, K. C. -- Brit. Jnl. Actinotherapy, November, 1928.
    106. Eidinow, A. -- Brit. Med. Jnl., August 17th, 1929.
    107. Perlman, H. H. -- Archives Phys. Therapy, December, 1929 (Quartz Lamp, February 1930).
    108. Furniss, A. -- Brit. Jnl. Actinotherapy, December, 1930.
    109. Huntemuller, O. -- Strahlentherapie, 1930, 35, 489-500.
    110. Sanford, H. N. -- Archives Phys. Therapy, March, 1930 (Quartz Lamp, May, 1930).
    111. Levine, V. E. -- Archives Phys. Therapy, July, 1931 (Quartz Lamp, September 1931).
    112. Leopold, J. S. & Bernhard, A. -- Am. Jnl. Dis. Children, April, 1932 (Quartz Lamp, N., May, 1932).
        Also Nos. 595     831     848

Metabolism.

    113. Rothmann, S. & Callenberg, J. -- Klin. Ws., September 17th, 1923.
    114. Pincussen, L. -- Strahlentherapie, 1924, 18, 625.
    115. Steenbock, H. -- Phys. Therapeutics, May, 1926.
    116. Firth, J. B. & Russell, W. K. -- Brit. Jnl. Actinotherapy, June, 1927.
    117. Fairhall, L. T. -- Amer. Jnl. Physiology, 1928, 84, 378-385.
    118. Ferri, U. -- Clinica Ped., 1928, 10, 129 (Quartz Lamp, November, 1928).
    119. Lippman, A. & Volker, H. -- Klin Ws., January 29th, 1928 (Brit. Jnl. Actinotherapy, May, 1928).
    120. Davis, S. -- Phys. Therapeutics, November, 1929.
    121. Arnautov, A. & Weller, E. -- Zs. f. d. ges. Exper. Med., May 16th, 1931 (Quartz Lamp, September 1931).
    122. Brown, W. L. -- Post-graduate Med. Jnl., November, 1932.
    123. Chick, H. -- Lancet, August 13th, 1932, 20.
        Also Nos. 22     134     588     589     595

General.

    124. Hausmann, W. -- Grundzuge der Lichtbiologie und Lictpathologie (1923).
    125. Hausmann, W. -- Strahlentherapie, 1923, Suppl. 8, p. 103 (Quartz Lamp, February, 1924).
    126. Eidinow, A. -- Brit. Jnl. Tuberculosis, July, 1925.
    127. Hill, L. -- Nature, May 2nd, 1925.
    128. Hill, L. -- Brit. Med. Jnl., September 12th, 1925.
    129. Bachem, A. -- Archives Phys. Therapy, December, 1926.
    130. Eidinow, A. -- Brit. Jnl. Radiology (B.I.R.), January, 1926.
    131. Meyer, P.S. -- Zentralbl.f.Haut Krankheiten, 22, 1926, 713-742.
    132. Rost, G. A. -- The biological basis of ultra-violet therapy (1926, 1/-).
    133. Baly, E. C. C. -- Dental Surgeon, October 8th, 1927.
    134. Hausmann, W. -- Die allgemeinen Grundlagen der Lichttherapie (in Handbuch der Lichttherapie, ed. Hausmann & Volk), 1927.
    135. Kime, E. N. -- Phys. Therapeutics, December, 1927.
    136. Laqueur, A. -- Lichttherapie innerer Erkrankungen (in Handbuch der Lichttherapie, ed. Hausmann & Volk), 1927.
    137. Sonne, C. -- Strahlentherapie, 28, 1928, 45-51.
    138. Pincussen, W. -- Photobiologie; Grundlagen; Ergebnisse; Ausblicke (1930, Mk.36).
    139. Downes, A. -- Sunlight, Summer, 1932.

    To win the patient's understanding and co-operation it is helpful to explain briefly that actinotherapy is the therapeutic use of rays similar to those found in sunlight, but of greater intensity; that these ultra-violet rays have powerful bio-chemical effects, raise the bactericidal power of the blood, and increase resistance to infection. (See the useful notes given by Dr. L. C. Donnelly in his paper "How I use ultra-violet energy," No. 832). A brief talk can be suited to the circumstances of the case. Explain that little or nothing will be felt during the actual treatment, and advise what reaction will follow. If this is expected to be severe, prescribe suitable alleviatives (see page 40). Stay in attendance with each patient during the earily treatments.
    When actinotherapy is first administered in chronic conditions, the first results may be reinoculation of the patient and a temporary exacerbation of symptoms. This is frequently observed and is usually a good prognostic sign.

Records.

    Time and distance of each irradiation should be noted on the case-record card, and the resulting reaction entered at the next visit.*   (*Special Record Cards for Light Treatment are supplied by the Hanovia Co. through its dealers and agents.)

Individual Treatment.

    In private practice, it is most convenient to treat the patient on a couch. If not over 20 inches high this allows the Alpine Sun burner to be raised 40 inches from the patient. Keep the treatment room warm (70-75 degrees F.), or use the Sollux Lamp for warming the patient. The operator and any attendants must wear goggles; the patient should also do so, but may be allowed to dispense with them provided the eyes are kept shut.
    Have the lamp in position by the couch before switching on. The burner should not be directly over the patient. When it is running at full output the patient, undressed, lies flat on the couch and the timing clock is started. If back and front are being irradiated 2 minutes each, set the clock for four minutes and instruct the patient when to turn over.
    The skin should be quite clean, divested of grease, powder, etc., before treatment. A hot bath or shower will both cleanse the skin and improve its circulation, thus promoting the actinic reaction. Loin slips are often worn during treatment; except for these, the greatest possible area of skin should be exposed for tonic irradiation.

Collective Treatment.

    In large scale clinics using the Jesionek Lamp, patients are usually treated standing or sitting. Distance of exposure is regulated by graduated circles marked on the floor, and it is a simple matter to ascertain the time for an average erythema reaction at each distance. Take individual tests to ascertain any personal idiosyncrasy, so that patients can be grouped for treatment suited to the needs of each case.

Dosage.

    Several factors must be considered in correct dosage. These include:

    Apparatus -- quality and intensity of radiation emitted.

    Exposure, considered under:
        (a) Distance (from lamp to patient).
        (b) Time of exposure.
        (c) Area of skin exposed to the rays.

    Frequency of irradiaton (intervals between exposures).

    The patient, with special regard to:
        (a) Constitutional factors.
        (b) Condition, ascertained after diagnosis.

    It is impracticable to standardize technique in terms of minutes and inches, in view of the number of variant factors. So far as any indications for exposure are given here, e.g., on the Erythema Chart (page 42), they should be understood as referring to a patient with an average skin reacton and to a Standard Alpine Sun burner (A.C. type or D.C. at 200-500 volts) of 1932 type which has been used not more than 100 hours.

Apparatus.

    In this handbook, the technique of ultra-violet irradiation is standardized on erythema reactions (see below). The practical test of an actinic source is its power to evoke an erythema on the skin in reasonable time. If, on test, a lamp does not fulfil this condition, it should be renewed or replaced. For clinical work, it is essential to standardize the map output at intervals.
    The Standard Alpine Sun and Kromayer Lamps are less powerful when set to operate on low voltage Direct Current circuits. Compared with the higher voltage models, these lamps would require about 50 per cent. increase in exposure. As the standard voltage in the United States is 110, over-dosage would result from applying the time and distance factor stated by American writers to high voltage lamps without correction.
    The practitioner should, at the outset, and periodically, standardize his own lamp by skin test, preferably on himself. This will ensure that he is familiar with the various degrees of erythema reaction, and repetition of the test (say, after each 100 or 200 hours of burner use) will obviate errors due to differences in personal reactions. A simple and practical method is as follows:

Air-cooled Lamp.

    Light the lamp and allow it to burn for 10 minutes (Standard Alpine, until operatometer needle is steady). Then take a series of five exposures on the inner forearm, at a uniform distance of 10 inches from the burner. Each exposure should be made through an aperture about half-an-inch in diameter, keeping the rest of the skin covered. Convenient times are 1, 1 1/2, 2, 3, 6 minutes. On the following day observe the result, and repeat at 40 inches distance for times of 3, 5, 10 minutes. If the forearm is pigmented such tests should be made on the abdomen.

Kromayer Lamp.

    Using the same method, after the lamp has burnt 5 minutes, hold the window in contact with skin of inner forearm for 10 seconds, at other spots for 25 seconds, 40 seconds and 1 minute. Next day repeat (on other arm) at 2 inches distance, for 30 seconds, 1, 2, and 5 minutes. Use a sheet of paper with cut aperture for these distance irradiations. The reactons, 1-2 days later, make it easy to standardize the erythema output of a lamp, in terms of a personal reaction. Keep a record of time, distance, and reaction, and repeat the tests when the lamp has given 100 hours operation, then after 200 hours, and so on. Thus you arrive at factors expressing the intensity of a lamp in terms of its erythema production.

Sollux Lamps.

    These lamps produce no erythema and no latent reaction. Their therapeutic effect is an immediate deep-tissue hyperaemia.

Exposure.

    (a) Distance. For convenience of measurement, a distance gauge is manufactured for use with any model of the Alpine Sun Lamp. In large clinics using the Jesionek Lamp, it is useful to fix lamp distances by white lines permanently marked on the floor.
    Whilst the mercury arc is not a point source of radiation, the inverse square law is roughly true for the intensity of its radiation.*   (*For more accurate calculation of the dose at varying distances, the formula: I = t/d1.6 is considered valid for the air-cooled burner with reflector, and has been used in calculating the table on page 35.)  Note that this does not apply to the quality of the rays; due to differential absorption by air, irradiation from a short distance (10 inches) has a greater proportion of short-waved, counter-irritant, bactericidal rays than from 30 to 40 inches. Sampson (786) distinguishes between long-wave and short-wave technique on the distance basis alone.
    The following reference table shows the relative intensity of uniform time exposures given at different distances:--
 

Distance  (inches).	40	31	26	22	20	17	14	12	10
Proportionate Dose.	1	1 1/2	2	2 1/2	3	4	5+	7	9

 
    (b) Time. Timing clocks are essential in the treatment. They should be specially made to ring a signal at the end of a set period which can be accurately measured in minutes. There are two standard Hanovia timers made in this way: the Large Timer (setting up to 30 minutes), and the Small Timer which sets to 6-minute intervals.
    (c) Area of skin exposed. This is a dependent variable. In most conditions for which general body baths are prescribed, as much of the body surface as possible should be exposed to irradiation at each exposure. Special conditions (e.g. angina pectoris) indicate a sharp reaction over a limited area; Part II of this book gives details. The blister dose (fourth degree erythema) is never given except on a very small area.
    Eidinow (147) states that maximum increase in haemo-bactericidal power is produced by irradiating only one-fourth of the body area at a time with a minimal erythema exposure three times weekly. As a working procedure, however, this does not appear to have found general acceptance.

Frequency of Irradiation

    Intervals between treatment will vary according to the condition present and the severity of any previous skin reaction. As a general rule, do not apply repeat irradiation until the previous reacton has subsided. Authorities vary widely in their procedure for courses of light treatment, and some attempt is made below to clarify this matter by instancing typical courses of general irradiation.*  (*It is appropriate to emphasize here that these times and distances are not hard and fast guides. The patient's reaction to any irradiation gives the best guidance for correct exposure at the next treatment.)

Tonic Course.
 

Dose	Distance (inches)	Time (minutes)	Interval (days)	Relative Dosage	Skin Reaction	Remarks
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15	40 40 40 40 40 40 40 40 40 40 40 40 40 40 40	3 4 5 6 7 8 9 10 11 12 13 14 15 15 15	2 - 3 days interval between treatment.	1   2   3     4 5	First degree erythema.	Visible erythema at first exposure, then time increased gradually at constant distance.

    (Do not increase over this time or decrease standard distance. If pigmentation results, intermit treatment 3-4 weeks and recommence with initial dose.)

Typical Conditions. Neurasthenia, digestive disorders, anaemia, hyperpiesis.

Book Nos. 140-159 DOSAGE

Sedative Course.
 

Dose	Distance (inches)	Time (minutes)	Interval (days)	Relative Dosage	Skin Reaction	Remarks
1 2 3 4 5 6 etc.	40 40 40 40 40 40	1-2 1-2 1-2 1-2 1-2 1-2	Given daily or every second day.	Constant.	Suberythema.	The very slight reaction is repeated at each exposure, avoiding any pigmentation.

    Typical Conditions.  Severe anaemia, asthma, debility, convalescence.

Therapeutic Course.
 

Dose	Distance (inches)	Time (minutes)	Interval (days)	Relative Dosage	Skin Reaction	Remarks
1 2 3 4 5 6 7 8 9 10 11 12	40 38 36 34 32 30 28 26 24 22 20 20	3 6 9 12 15 18 21 24 27 30 30 30	1 - 3 days interval between treatment.	1 2 1/4 3 1/2 5 7 9 12 15 20 26 30 30	2nd erythema. Pigmentation. Pigmentation. Pigmentation. Pigmentation. Pigmentation. Pigmentation. Pigmentation. Pigmentation. Pigmentation. Pigmentation. Pigmentation.	Definite erythema to be produced after each exposure.  After 12 sessions interpose 3 - 4 weeks break.

 
    Typical Conditions. "Surgical" tuberculosis, rickets, neuralgia, skin diseases, endocrine deficiency.
    Note: If an accidental break occurs during the course, take the last dose given and count the break period backwards; e.g., if two weeks break occur after No. 6, recommence with No. 3 (given two weeks before the break).
 
The Patient.

    Constitutional Factors. In fixing the initial dose, the best procedure is to ascertain each patient's sensitiveness by previous tests on small areas. There are wide variations due to:-

    Sex. Women require about 75 per cent. of the dosage applicable to males.

    Age.Children require about half the adult dose; infants about a quarter. (Note. Infants up to 3 years old may not develop erythema reaction).

    Skin. Tanned skins, dark complexions, thick fatty skins, all indicate increased dosage. Fair skins, red hair, special sensitiveness to sunlight indicate caution and a small starting dose. Albinos will probably react to a minimal dose.. Long-standing syphilis or malaria may cause violent reactions.

    Weight. Some experts state that muscular and corpulent subjects show best results when irradiation is given frequently and dosage steadily increased, whilst those patients of active nervous temperament react best to smaller doses once or twice weekly only.

    Body area. Different areas of the body surface react differently to actinic rays. Bach gives a useful table of relative sensitivity as below:
 

100 per cent.	Abdomen, chest, back, pelvis.
75 per cent.	Inside forearm, outside arm.
50 per cent.	Neck, face, thigh, calf.
25 per cent or less.	Hands, soles of feet.

 
    Special Factors. Hypersensitive patients are rare, and will usually be aware of their idiosyncrasy to natural sunlight.
    Reaction will also be increased by any measures which promote skin-circulation, such as hot baths, luminous heat, massage, etc., applied before irradiation. It is poor technique to irradiate a skin that is cold and sluggish.

Erythema.

    The skin erythema following ultra-violet radiation develops after a latent period which may vary from one to eight hours. It is a skin flush accompanied by vascular dilation. The degrees usually distinguished are the following:

Sub-erythema.

    No visible reaction, the dose being determined as one quarter of the second degree erythema.
    Synonym: "Sedative dose."

    1st Degree.  A reaction so slight that it is scarcely noticed by the patient. The skin reddening is very faint, occurs after a latent period of some hours, usually subsides within one to two days, and is not followed by visible exfoliation. Should be administered on the entire body, or largest possible area.
    Synonyms: "Ultra-violet douche"; "Minimal erythema dose"; "Tonic dose."

    2nd Degree. A mild sunburn reaction. The reddening is plainly visible and is followed on subsidence by slight granular exfoliation. Subsides in about three days, leaving some pigmentation.
    Synonym: "Stimulative dose."

    3rd Degree. An intense reaction similar to severe sunburn. The reddening is intense and the epidermis can be peeled off in large strips. Takes about a week to subside, leaving pigmentation. Essentially a local reaction.
    Synonyms: "Regenerative erythema"; "Counter irritant dose"' "Inflammatory stimulus."

    4th Degree. An intense reddening, supervening after a short latent period (about two hours) and deepening until exudation and blistering result; persists for many days. Only administered on small areas. Usually administered at contact, or short distance, and is thus also a bactericidal or sterilizing dose.
    Synonyms: "Dermatitis bullosa"; "Destructive dose": "Acute inflammatory stimulus."
    The erythema chart (page 42) gives data which will assist in correlating any required degree of erythema with the exposure factors. It should be carefully studied, but not blindly adopted as a hard and fast rule without regard to the patient.

Demarcation.

    It is simple to limit actinic reaction to any required body area, by covering the areas not to be exposed. Black paper cut to shape, plaster, etc., may be used. A very handy preparation is "Protectol" * ointment which can be used for protecting the nostrils, labia, and other areas not easily covered in other ways.

Alleviation.

    Any slight irritant following an ordinary tonic dose is easily alleviated by applying boracic or talcum powder. For more intense erythema, cold compresses (resorcin, aluminium acetate, boric lotion, calamine lotion, etc.) or ointment ("Hanoviol,"* 2 per cent. salicylic ointment, zinc oxide, etc.) may be applied. Where heavy reaction has been caused in a cavity (nostrils, etc.) a soothing suppository may be made up as below: (*Supplied by the Hanovia Co., and Agencies.)
 

Al. acet. (bas. Sol.). . . . . . . . . . . . . . . . 5
Lanoline . . . . . . . . . . . . . . . . . . . . . . . 10
Vaseline alb. . . . . . . . . . . . . . . . . . . . . 20

    If applied immediately after local overdose of actinic rays, irradiation with the Sollux Lamp, using the localizer and red filter, applied for 15-30 minutes, will obviate an undue skin reaction (see page 51).
 
Contra-indications.

    Contra-indications for phototherapeutic treatment include all those pathological conditions where the organism is incapable of summoning resources to make a reparative effort under the influence of ultra-violet rays.
    This is the case with almost all the cachexias and acute febrile diseases (congestive tuberculosis taking the first place). Ultra-violet appears equally contra-indicated in all the cases where the patients have to be maintained in complete repose. For example, gross renal, hepatic, or cardiac insufficiency.
    Under this heading must be included:
    Conditions of auto-sensitization (scarlet fever, small-pox, measles, pellagra, beriberi, xeroderma, hydroa aestivale, Addison's disease.
    Advanced arteriosclerosis.
    Advanced heart disease with failure of compensation.
    When there is any doubt whether actinotherapy should be administered, small doses should be the rule, and careful observation should be kept of pulse, temperature, and weight.

Photosensitization.

    Certain drugs, dyes and heavy metals cause photo-catalytic reactions when present in the system during actinic irradiation. In the hands of experts, some of whose publications are noted (page 44), this phenomenon has been utilized in therapeutic irradiation. Whilst photosensitization is not yet a widely used or fully understood procedure, the practitioner should be familiar with the commoner substances which evoke it, as cautious dosage of actinic rays is indicated when these are being administered:
    Drugs. Quinine, trypaflavin, eosine, chlorophyll, pyridine, gonacrine, methylene blue, and the other fluorescent dyes.
    Endocrines. Insulin, adrenalin, pituitrin, thyroid.
    Metals. Heavy metals circulating in the blood increase the effect of ultra-violet rays. Again, the effects of drug therapy in which these metals are administered are distinctly increased under the influence of the rays. This applies to mercury, iron, bismuth, gold, silver, etc., and especially to calcium and its salts.
    Desensitizers. It is stated that ingestion of the following substances retards actinic reactions:
        Resorcin (3 grains, taken one day before irradiation).
        Camphor and its derivatives.
 
 

REFERENCES TO LITERATURE.

Dosage.

    140. Mayer, E. -- Amer. Rev. Tuberculosis, October, 1922.
    141. Dahlfeld, C. -- Strahlentherapie, 1923, 16, 75-95.
    142. Keller, P. -- Strahlentherapie, 1923, 16, 1924, 17.
    143. Jesionek, A. & Rothmann, S. -- (In irrtumer der allgemeinen Diagnostik und Therapie, No. 4, 1924).
    144. Donnelly, L. C. -- Jnl. Radiology, May, 1925.
    145. Eidinow, A. -- Lancet, August 15th, 1925.
    146. Hill, L. & Eidinow, A. -- Practitioner, August, 1925.
    147. Eidinow, A. -- Lancet, September 25th, 1925.
    148. Thedering, F. -- Brit. Jnl. Actinotherapy, November, 1927.
    149. Thedering, F. -- Strahlentherapie, 1928, 28, 602-610.
    150. Kovacs, Anderson, Bridge, et al. -- Med. Jnl. & Record, December 4th, 1929.
    151. Furniss, A. -- Brit. Jnl. Actinotherapy, June, 1930.
    152. Blumenthal, Keller, Lomholt, et al. -- Derm. Ws., September 5th, 1931.
        Also Nos. 744 786 790 791 793 796 799 852

Contra-indications

    152a. Dufestel, L. G., et al. -- Brit. Jnl. Actinotherapy, April, 1928
    152b. Hickel, R. -- Reactions, incidents, accidents, provoques par les rayons ultra-violets (1932. 15 frcs).

Photosensitization.

    153. Ostermann, M. -- Brit. Jnl. Actinotherapy, September, 1926.
    154. Courmelles, F. -- Phys. Therapeutics, February, 1928.
    155. Jausion, H. -- ler Conf. Int. de la Lumiere, Lausanne, 1928.
    156. Lassen, H. C. A. -- Strahlentherapie, 1928, 27, 757-768.
    157. Hindley-Smith, J. D. -- Brit. Jnl. Actinotherapy, April, 1929.
    158. Woodbury, F. T. -- Phys. Therapeutics, December, 1929.
    159. Eidinow, A. -- Brit. Jnl. Radiology, March, 1930.
        Also No. 132 152b 789 (Chap. 13); 796 797 831 898
 

APPLICATORS FOR THE KROMAYER LAMPS

    As a guide in selecting applicators, the standard forms in use are illustrated and briefly described below:

No.
 

*501 Round rod, 17 x 80 mm.  *502 Round rod, 12 x 80 mm.	(These are of general utility, e.g., for treating nodules, small ulcers, gingiva, conjunctiva, etc.
*503 Round rod, 5 x 80 mm.	For the auditory canal.
504 Wedge (adults) 10 x 80 mm.  505 Wedge (children) 8 x 74 mm.	Designed for nasal irradiation.  These applicators have a centimetre scale etched on the quartz to assist in regulating exposure. Also useful for irradiating a narrow sinus.
*506 Curved rod, 11 x 110 mm.	Laryngoscope, designed by Dr. Sampson for laryngeal tuberculosis. Also used in dental surgery for gingival irrradiation on lingual aspects.
507 Hooked rod (spatulate tip) 8 x 150 mm.	Introduced by mouth for irradiation of naso-pharynx.
508 Rod (flattened at tip) 6 x 140 mm.	For irradiation of nostrils and posterior nares; deep sinus work, etc.
*510 Rod (with forked end)	Dr. Hindley-Smith's special tonsil applicator.
522 Socket disc.	This (with No. 523) is essential for fixing any applicator to the Kromayer Lamps. It embodies a three-way lever giving white (unfiltered) light, blue light, or cut-off, as required.
523 Holder.	For the Standard Kromayer Lamp, used with No. 522 for attachment of any rod applicator.
523a. Holder	For the Kromayer Lamp (Model II). Similar to No. 523.
524. Lens cover (metal).	For Kromayer Lamp . Safety screen for use when lamp is lit, but not being applied.
581. Lens cover (mica in metal frame).	For Kromayer Lamp (Model II). Serves same use as No. 524.
525. Uviol blue window (in metal frame).	For Standard Kromayer Lamp. Applied in front of the lamp window. Cuts off the shorter ultra-violet rays (below 2800 A.U.) giving a milder radiation with deep penetration. Necessitates about four times the exposure of unfiltered radiation. (See pages 14-46).
525a. Blue window (in metal frame).	For Kromayer Lamp (Model II). Same purpose as No. 525.
526. Diagnosis filter (in metal frame).	For Standard Kromayer Lamp. Applied in front of the lamp window. This filter serves for fluorescence -- diagnosis of skin infections, e.g., ringworm. (See pages 14-142).
526a. Diagnosis filter (in metal frame).	For Kromayer Lamp (Model II). Same use  as No. 526.
^527. Crystal quartz window.	(Spare part for the Standard Kromayer Lamp). To be inserted with the bevel edge outward.
^528. Medium Skin Lens, 28 mm.  0	Used in compression treatment for dehaematization and deep penetration.
^529. Small Skin Lens.  20 mm.  0	Used in compression treatment for dehaematization and deep penetration.
^530. Large Skin Lens, 30 x 34 mm.	Used in compression treatment for dehaematization and deep penetration.
532. Round rod, 8 x 50 mm.	For gingival work.
*552. Round rod with half bend, 5 x 100 mm., tapered	Pyorrhoea applicators, for penetration of pus pockets. Also valuable in ophthalmic work to irradiate conjunctival fornices, small ulcers, etc.
*553. Round rod with right angle bend, 5 x 100 mm. tapered tip.	Pyorrhoea applicators, for penetration of pus pockets. Also valuable in ophthalmic work to irradiate conjunctival fornices, small ulcers, etc.
*554. Round rod, 12 x 100 mm.	For facial aspects of gingiva and irradiation of small foci elsewhere.
*555. Curved rod, 12 x 120 mm.	For lingual aspects of gingiva and other oral lesions.
556. Bayonet rod, 6 x 170 mm.	Designed by Dr. Zilz for irradiating oral lesions of difficult access.
^557. Conical oral applicator, 100 mm. long, tapering to 15 mm.  0	This applicator gives heavy concentration of the rays on a small area, ensuring heavy reaction with short exposure.
*558. Right angle rod with bulbous tip, 8 x 110 mm.	Primarily for irradiation of tooth sockets after extraction.
571. Rod, olive shaped tip, 6 x 170 mm.	A long rod for urethral irradiation, also valuable for empyema and deep fistulae.
572. Rod, 5 x 70 mm.	A general utility rod applicator.
573. Quartz speculum, small, 32 x 112 mm.	For vaginal irradiation. The speculum is placed in the patient first and lamp brought up. A rod applicator affixed to the lamp can be used within the speculum to irradiate small ulcers, etc. The small speculum is also used for rectal irradiation in a similar way.
574. Quartz speculum, medium, 32 x 118 mm.	For vaginal irradiation. The speculum is placed in the patient first and lamp brought up. A rod applicator affixed to the lamp can be used within the speculum to irradiate small ulcers, etc. The small speculum is also used for rectal irradiation in a similar way.
575. Quartz speculum, large, 38 x 112 mm.	For vaginal irradiation. The speculum is placed in the patient first and lamp brought up. A rod applicator affixed to the lamp can be used within the speculum to irradiate small ulcers, etc. The small speculum is also used for rectal irradiation in a similar way.

 
*Rods thus marked are designed for localized reactions from their tips, and the quartz is metal-covered to obviate lateral radiation.

^These applicators are ground from crystal quartz, and must be sterilized cold with alcohol, etc. All other applicators are of fused quartz and may safely be sterilized by boiling. Remember that the ultra-violet rays are themselves powerful bactericidal agents and will quickly destroy any germs on the window or rods.
 

Fig 3. APPLICATORS FOR THE KROMAYER LAMPS       The technique of irradiating the membranes which line orifices of the body necessitates applicators of suitable design. The forms here illustrated are, in nearly every case, designed by specialists in the various branches of medical work under which they are classified. Details of dimensions and uses are stated opposite.       The specifications of applicators given under the different indications in Part II of this work are referred to the numbers here quoted.

 

Local Irradiation.

1. Kromayer Lamp.

    It should be remembered that local irradiation with the Kromayer Lamps is a different procedure to treating a small area with the air-cooled models. The shorter ultra-violet rays, which have most powerful bactericidal properties, are readily absorbed by air. With the Kromayer Lamps, the radiation penetrates only 1/2 inch of water. This filters out the infra-red rays, but transmits the ultra-violet rays above 2000 A.U. practically unweakened.* Application of window or rod in contact means utilizing these short bactericidal rays in full intensity.  (* The diagram on page 18 shows the output of the Kromayer Lamp.)
    In distant irradiation, the Standard and Model II Kromayer Lamps should usually be applied about 2 inches from the skin surface, at right angles. If well defined, the lesion may be demarcated by plaster, or black paper cut to shape and applied to the skin. Remember that in treating ulcers, erysipelas, etc., it is essential to include a margin of healthy skin when giving treatment.
 
2. Alpine Sun Lamp.

    To produce a second or third degree erythema on the scalp, face, a limb, etc., it is usually sufficient to cover the unexposed areas and bring the Alpine hood to correct distance. Remember that the rays should always be directed at right angles to the treatment surface.
    Lesions which are quite small, and where heavy reactions are not indicated, may be radiated through the aperture in the Alpine Sun lower hood. Do not apply the Alpine Sun at less than 8 inches burner-to-skin distance.

Compression irradiation.

    Ultra-violet rays are absorbed in the capillary blood vessels. When the skin is dehaematized by compression, the rays penetrate into the deeper epithelial layers.
    The quartz window of the Standard Kromayer Lamp may itself be applied directly to the skin in compression treatment. More effective dehaematization is secured by compression through one of the skin lenses (Nos. 528-530).
    Deepest penetration is obtained by using the blue filter in contact with the Kromayer Lamp window, and giving about four times the normal unfiltered light exposure to produce an equal degree of erythema.
    Where a long exposure under compression is given, it is sometimes found convenient to bind the lamp burner firmly into position. When using this procedure with the Standard Kromayer Lamp, take care that the burner is maintained in correct position throughout treatment.
    The lamp front can be sterilized after use by washing with sublimate solution.

Treatment with applicators.

    A quartz rod transmitting ultra-violet rays acts as a lens throughout its length. Practically the same quality and intensity of radiation which enters from the burner is emitted at the treatment end. The quartz rod obviates the losses in intensity and quality caused by air-transmission; still more, it allows the beam to be deflected so that irradiation can be applied to foci (larynx, etc.) which are inaccessible to direct irradiation.
    The successful use of the Kromayer Lamp depends largely on due employment of the applicators. Their various uses are described briefly below:

Skin Treatment

    Normal mucous membrane will tolerate about 50 per cent. greater exposure than the skin of the abdomen, but great variations occur due to pathological changes. For example, the nasal membrane may require only 30 seconds exposure in cases of hay fever, but 10 to 15 minutes for ozaena.
    When producing a heavy reaction in a cavity, measures should be taken to prevent blistering the skin (nostrils, labia, etc.) at its entrance. A practical way is to insert the applicator alone to the full length required, then grease the outside skin with "Potectol" or lanoline. Do not apply the grease first, or it will adhere to the applicator and interfere with treatment. After this is done, bring the Kromayer burner, ready lit and running at correct intensity, into position and affix to the applicator.
    The notes given under the various conditions in this handbook, combined with the descriptions of applicators following, will enable the practitioner to select applicators suitable for treating all indications.

Sinus irradiation.

    A deep, irregular sinus, fistula, or septic wound, may be irradiated by flooding the cavity with one of the photo-sensitive dyes and irradiating with the Kromayer Lamp and a suitable applicator (e.g., No. 571) dipping into the solution. The aniline dyes, eosine, acriflavine, gentian violet, fluorescein, in 1/1000 water or glycerine solution, are usually employed, or mercurochrome in suitable cases. Donnelly states that gentian violet has special affinity for staphylococci, streptococci, and anthrax; and acriflavine for gonococci, the colon and dysentery groups.

References:

    159a. Kromayer, E. -- Derm. Zs., 66, 1933, 79-84 (Quartz Lamp, S, July 1933).
        Also Nos. 837 913
 

    On a strict definition, "actinotherapy" means the medical application of short, actinic, ultra-violet rays, and indicates the use of "cold" actinic sources such as the quartz lamp. Its meaning is, however, extended to include all forms of light treatment.
    At the other end of the visible spectrum are the luminous heat and infra-red rays, generated by the sollux Lamps. This group of radiations form a valuable complement to the ultra-violet rays. They have greater power of tissue penetration, and take immediate action. These "thermal" rays do not produce the powerful secondary physiological reactions characteristic of the photo-chemical "actinic" rays; their effect is a deep penetrating hyperaemia of long duration. Locally, they produce a blood temperature exceeding the highest known fever, with consequent increase in the processes of oxidation and immunization (phagocytosis). This points to the indications for their therapeutic use in acute conditions associated with inflammaton and pain.
    Some conditions exhibit the best response under combined irradiation, in which both the actinic and thermal rays are utilized to reproduce the full range of sunlight. Frequently the heat rays are subsidiary: they serve only to warm the unclothed patient, to improve skin-circulation, and so prepare the way for a satisfactory actinic reaction. In certain conditions (e.g., rheumatism, neuritis) their action is essential to relieve the acute symptoms, whilst the subsequent actinic reaction assists to rebuild tone and promote recovery.
    The Sollux Lamp generates, in addition to invisible infra-red, a proportion of visible red and yellow radiation. Its output characteristics are reproduced on the special graph (page 18) with which is correlated a graph of the comparative tissue-penetrating power of different wave-lengths. Red light, and the shorter infra-red rays, are the most penetrative of all wave-lengths employed in light therapy; comparison of these graphs makes this evident. The longer-waved infra-red do not reach the underlying tissues, and tend to overheat the skin when applied in excess (177).
    The red filter with the Sollux Lamp produces a radiation with the maximum of deep penetrating rays in proportion to the other radiations present.

Technique.

    The reaction to these rays is visible during treatment in the form of hyperaemia; the irradiated area is deeply suffused with blood. Note that deep tissue hyperaemia reaction is the aim in most instances, and in producing this, precautions may be necesssary to prevent superficial burns. These are obvious; e.g., greasing the skin before the first treatment; cooling the skin by an electric fan during irradiation, etc.

Local Irradiation.

    Either the Standard Model (1000-watt bulb) with localizer fitted, or the small model (300-watt bulb) may be used. The technique is similar for both lamps, but the Standard Lamp will naturally produce speedier results.
    When using the Standard Lamp for local treatment, do not switch on full intensity. Move the resistance setting back to stud 4 or stud 3, otherwise internal overheating may destroy the bulb. Never cover the lamp with draperies.
    Place the patient in a comfortable position, preferably reclining, and adjust the lamp so that the rays are concentrated on the focus of the inflammation to be treated. With the Standard Lamp, attach the localizer.
    The distance of skin from the cork ring of the reflector should be as short as the patient can tolerate without discomfort. In practice this is found to be about 6 inches for the first treatment, which can be reduced to 3 or 4 inches at subsequent sessions. Delicate skins (e.g., young children, blonde females) may necessitate precautions as outlined above to prevent superficial burns.
    To produce the required deep tissue hyperaemia, prolonged irradiation is essential. The first treatment should be not less than 20 minutes, and local irradiation may safely be prolonged up to an hour at each session. Local treatment may be repeated daily, or twice daily, or even more frequently in acute conditions.

Precautions.

    When irradiating the face, the eyes should be protected by the use of cloth pads, or special goggles proof against infra-red rays. The patient should avoid exposure to cold or draughts soon after treatment.

General Irradiation.

    Use the 1000-watt Model Lamp. If a special region requires treatment (e.g., the thorax in pleurisy or pneumonia) demarcate by clothing, etc. Distance should be the shortest possible consistent with uniform irradiation over area. Maximum time 60 minutes each session.
    In giving combined heat and ultra-violet therapy, always administer luminous heat before or during the actinic radiation. The eyes should be shielded from the rays.

The Colour Filters.

    Red light is stated to be "antagonistic" to ultra-violet rays in its therapeutic action. Thus a local overdosage of quartz light can be counteracted by local irradiation for at least half-an-hour with red light; this will obviate the blistering and severe pigmentation which would otherwise follow:
    The therapeutic indications for red light are:
    (1) After-treatment of local, actinic overdosage. In such conditions as seborrhoea and acne where it is necessary to bring about severe reactions with the quartz lamp, after-treatment with red light will effect quicker restoration of healthy skin and obviate severe pigmentation (164 173).
    (2) For drying up acute weeping forms of eczema (795).
    (3) For the treatment of pustular eruptions on the skin; in such cases healing takes place without scars.

    Blue light, used for prolonged local irradiation, is stated to cause local anaemia. It has been used:--
    (1) For pre-operative treatment, to cause local anaesthesia (assisting cocaine, etc.)
    (2) As an anodyne in articular and traumatic extravasations.
    (3) For treating trigeminal neuralgia and acute coryza.

    The Daylight Filter has no therapeutic value, but is useful in dental and surgical practice for diagnosis and other purposes which necessitate a colour-true light.

REFERENCES TO LITERATURE

    160. Cemach, A. -- Monats. f. Ohrenheilk., 1922, 56, No. 7
    161. Sonne, K. -- Strahlentherapie, 1925, 20, No. 1, and Phys. Therapeutics, April 1926.
    162. Benoist, C. -- Amer. Jnl. Phys. Therapy, October, 1926, and Brit. Jnl. Actinotherapy, September, 1926.
    163. Levick, G.M. -- Brit. Jnl. of Rad., May 1926.
    164. Guillaume -- Bull & Memoires de la Soc. Med. des Hospitaux de Paris, 1926.
    165. Kraft, F. de., et al. -- Phys. Therapeutics, April, 1927.
    166. Gill, A. B. -- Jnl. Amer. Med. Assn., October 8th, 1927.
    167. Kellog, J. H. -- Phys. Therapeutics, October 1927.,
    168. Heusner, H. -- Therapeutische Monats., 1928, No. 6.
    169. Johnson, W. T. -- Phys. Therapeutics, January, 1928.
    170. Goodman, H. -- The Physics and Physiology of infra-red radiation (Heat), 1929.
    171. Kellog, J. H. -- Brit. Jnl. Actinotherapy, March 1929.
    172. Sonne, K. -- Archives Phys. Therapy, March, 1929.
    173. Shattock, F. M. & Waller, M. -- Lancet, November 2nd, 1929.
    174. Brown, R. K. -- Brit. Jnl. Actinotherapy, April, 1930.
    175. Troup, W. A. -- Therapeutic Uses of infra-red rays (1930).
    176. Halla, F. v. -- Deutsche Aerzte-Zeitung, March, 1931, No. 253 (Quartz Lamp, S., January, 1932).
    177. Hill, L. -- Brit. Jnl. Phys. Med., September, 1931.
    178. Libbert, E. L. -- Amer. Med.,April, 1932 (Quartz Lamp, N., July, 1932).