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1 Department of Radiation Oncology, Levine Cancer Center, University of Massachusetts Medical School, 33 Kendall St., Worcester, MA 01605.
Received May 22, 2006;
accepted after revision September 12, 2006.
Address correspondence to J. N. Aronowitz
(aronowij{at}ummhc.org).
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CONCLUSION. The century-long experience with electrotherapeutics and the concurrent adoption of ultraviolet light therapy, facilitated the swift inclusion of X-radiation into medical practice.
Keywords: biomedical engineering • electromagnetic radiation • radiotherapy
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...we have just now discovered a medicine of the last importance to mankind.—T. Gale, 1802 Electricity, or Ethereal Fire Considered [1]
It is well documented that X-rays were used both diagnostically [2] and therapeutically [3] within months of their 1895 discovery; within a decade, several clinical radiology and radiation therapy texts were published [4-8]. This essay explores the events of the 18th and 19th centuries that facilitated the swift adoption of Roentgen's discovery into medical practice.
Electricity and Electrotherapy
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Thorough investigation of electricity's therapeutic efficacy, however, awaited a more reliable and convenient source. The ancients generated static electricity by rubbing a non-conductor, such as amber (the Greek word for amber is elektron). Otto von Guericke (1602-1686), a Prussian burgomaster, mechanized the process in 1663. His electrostatic generator consisted of a sulfur sphere rotating on an axle; a charge accumulated on the surface of the sphere when brushed by the operator's finger-tips. Isaac Newton, Francis Hauksbee, and others improved on the mechanism (Fig. 1A). The Leyden jar, a simple device to store an electric charge, was invented in 1744 (Fig. 1B).
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Orthodox medical practitioners disdained electrotherapy. A notable exception was the physician and revolutionary Jean-Paul Marat (1743-1793), whose published investigation, Memoires sur l'Electricite Medicale (1783), was widely admired [11]. Most of the early interest in electrotherapeutics was among natural philosophers—static electrotherapy was called franklinism—and clergy. John Wesley (1703-1791), the Methodist divine, was concerned about the inaccessibility of medical care for the poor [12]. He established several dispensaries; wrote a self-help manual, The Primitive Physick, in 1747; and proposed electricity as "the noblest Medicine yet known in the World" in a text, The Desideratum, or Electricity Made Plain and Useful by a Lover of Mankind and of Common Sense (1759).
Current electricity was first generated at the close of the 18th century. Nerves had long been assumed to transmit sensation and muscular stimulation by conducting "a very subtle humor." By the mid 18th century, physiologists speculated that the humor was electricity. Luigi Galvani (1737-1798) provoked contractions in dissected frogs' legs, attributing the phenomenon to innate "animal electricity" (1791). Alesandro Volta (1745-1827) refuted this conclusion, maintaining that the current arose from the dissimilar metals contacting the frogs' limbs. To prove his hypothesis, he created the voltaic pile in 1800, which generated a stream of electricity from stacked copper and zinc discs.
Galvani and Volta were disputants in "The Great Biologic Problem" [13]. Vitalists believed in an ethereal vital force as the source of animation. Materialists mundanely attributed life to purely chemical, physiologic, and physical processes. The debate, which touched on the nature of the soul, inspired Mary Shelley's Frankenstein in 1818 [14]. Although Volta won this battle, electrophysiologic discoveries in the 19th century were to vindicate Galvani, and treatment with chemically generated currents was to become known as galvanism.
Michael Faraday's (1791-1867) investigations into the interaction of electric and magnetic fields lead to the discovery of induced currents. He showed that a moving magnetic field or a fluctuating electric field, generated a current in a nearby circuit. These principles were applied in the magnetoelectric generator—or dynamo—and the induction coil, which uses a low-voltage galvanic current to generate a high-voltage alternating one. The use of such currents in medicine became known as faradism.
Organized medicine was hesitant to accept the integration of electrotherapy. The fledgling specialty's reputation suffered from the unsubstantiated claims of early researchers, painful treatments applied by untrained "medical electricians," and the activities of charlatans. Electrotherapy was all but abandoned by the end of the 18th century.
A Medical Revolution
But the 19th century brought cataclysmic changes to medicine. Bleeding,
blistering, sweating, and purging had been medical main-stays since Galen's
time. But advances in histology, physiology, microbiology, and pathology
rendered these practices untenable and their toxicity unacceptable. Nineteenth
century physicians sought alternatives to the humoral system of medicine. A
New Hampshire farmer, Samuel Thomson (1769-1843), rekindled interest in
botanical therapy. Many U.S. physicians adopted his methods into a system they
called physiomedicine
[15]. A Silesian peasant,
Vincent Priessnitz (1799-1851), devised a regimen of cold douches and
compresses, hydrotherapy, which became popular in Europe. Homeopathy
and systems of spinal manipulation were introduced. Electrotherapy was
reconsidered.
Medical electricity gained credibility from the work of prominent physiologists and neurologists. Carlo Matteucci (1811-1868) and Emil DuBois-Reymond (1818-1896) showed that muscles and nerves generate currents, establishing a rationale for electricity-based therapy. A lecture series by Golding Bird (1814-1854) to the Royal College of Physicians in 1847 showed that electricity warranted medical attention [16, 17]. Guillaume Duchenne (1806-1875) devised a technique called localized faradization to stimulate nerves without injuring overlying skin [18]. His treatise on electrotherapy, De l'Electrisation Localizee (1855), became a classic of neurology, neuropathology, and electrophysiology. Duchenne was the leader of the French school of faradists, which included Jean Martin Charcot (1825-1893). Robert Remak (1815-1865) led the German school of galvanists. Remak was a respected neurohistologist for whom several structures are named and a pioneer embryologist. He demonstrated cell division and first described the three germinal layers [19]).
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Treatment was multimodal, using sedatives, tonics, diet, rest, travel, "mental therapeutics," and, of course, electrotherapy, which Beard characterized as "the most important and efficient remedy." His magnum opus, A Practical Treatise on the Medical and Surgical Uses of Electricity [23], went through 10 editions. Although initially greeted with skepticism [24], neurasthenia was eventually accepted because it filled a diagnostic need. The previously recognized psychiatric entities of insanity, hysteria, and hypochondriasis were unflatteringly stigmatized. Neurasthenia was a disorder of productive members of society, had a somatic albeit vague cause, and was treatable. By the turn of the 20th century, it had become the most frequently diagnosed nervous disorder.
Theory and Indications
Electrotherapy was initially explained in the context of the prevailing
doctrine of humoralism. Electric shocks and currents were believed to relieve
obstructed flow and congestion by reducing humoral viscosity. Eventually,
electricity itself was treated as a humor—the vital principle or nervous
force. Poor health was considered an imbalance of negative and positive
electricity. Treatments called electrical baths were thought to
correct deficiencies, and excesses were drawn off as sparks.
Currents were alleged to have salubrious nutritive effects, by enhancing circulation—reflex vasodilation—and by stimulating trophic nerves [25]. Because galvanic currents caused electrolysis of water, it was assumed that effusions, inflammatory products, tumors, and even ectopic pregnancies could be similarly disintegrated.
Electrotherapy's most acknowledged indication was the diagnosis and treatment of neurologic disorders. Central galvanization or general faradization was used for CNS disease. Peripheral nerve disorders were treated by local faradization or galvanization. Electrically induced muscle contractions were used to inhibit atrophy in the paralyzed and bedridden.
Electrotherapy played a prominent role in the diagnosis and treatment of psychiatric disorders [26-29]. Electrical stimulation could differentiate physical disorders from hysterical ones. Neurasthenia, neurosis, melancholia, hysteria, and hypochondriasis were common indications for electrotherapy. Paradoxically, electricity was used both as a stimulant and a relaxant. A positive static bath was a tonic, whereas a negative bath was a relaxant. Faradization was stimulating, whereas galvanization was applied for conditions of excitement or irritability.
Gynecology was a favored use for the galvanic current [30]. Hysterectomy, the standard treatment for many disorders, was a dangerous undertaking, with mortality rates of 4-20%, even in the hands of the few skilled gynecologic surgeons [31]. Therefore, safer options were sought. Weak currents—transdermal or intracavitary—relieved painful functional disorders, corrected uterine displacement [32] (Fig. 2), and reversed menstrual irregularities.
The use of strong destructive currents of several hundred milliamperes was introduced by the French gynecologist Georges Apostoli (1847-1900) [33]. Heavy uterine bleeding promptly ceased under the influence of an intrauterine anode. The electrolytic effect of a cathode within the uterine canal or introduced via forniceal puncture disintegrated fibroids and abetted resorption of the inflammatory products of endometritis and salpingitis [34].
Although electrotherapy rarely eliminated fibroids, shrinkage was often sufficient to relieve pressure on neighboring organs and reduce stress on supporting structures. Performed by a generalist and without anesthesia, electrotherapy became a safe and accessible alternative to surgery [35]. Abortionists also favored electricity because it left no physical evidence of the felony [36]. The treatment of ectopic pregnancy and malignancy by electrotherapy became a source of contention between operating and electrifying gynecologists.
Other disorders thought to be responsive to electrotherapy were myalgias, arthritis, angina pectoris, and prostatic hypertrophy. There were numerous ophthalmic and otolaryngolic indications. Aneurysms were coagulated by puncture with a galvanic, coagulating, anode. Constipation, "that bane of woman" [36], responded to intestinal toning by faradization by means of abdominal and rectal electrodes.
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Because patients with functional and neurotic disorders benefited most often from electrotherapy, it was suspected that its mechanism was suggestion [38]. Beard [39] affirmed the importance of engendering a positive expectation toward the attainment of favorable outcome. Although many physicians initially condemned the use of suggestion as deceitful, by the end of the century this tactic of mental therapeutics was recognized as a legitimate intervention [40].
Equipment
There were four recognized systems of electrotherapy at the close of the
19th century: franklinism, galvanism, faradism, and high frequency,
d'Arsonval, currents. A practitioner's choice of technique was based on
philosophical inclination, convenience, and equipment expense. Specialists in
electrotherapy used several types of apparatus. In practice, two forms of
electricity were often coupled. For example, batteries rotated the plates of a
static machine or an induction coil stepped-up a battery's voltage.
Interest in franklinism was rekindled by the introduction of influence machines [41] (Fig. 3A). The therapy units were massive, with up to 20 pairs of rotating discs, each typically 40-80 cm in diameter (Fig. 3B), and were capable of generating more than 100,000 volts. They could dispense staggering, even lethal, shocks. Franklinic therapy had several attractions. The equipment did not require significant maintenance, and the patient did not need to disrobe because sparks could be drawn through clothing, maintaining Victorian modesty and promoting office efficiency. The large whirling plates, crackling sparks, and ozone odor likely had a significant psychological impact.
Medical batteries were favored by generalists because they were inexpensive and could also serve as the power source for illumination, cautery, and esthetic work such as wart and nevus removal and hair electrolysis. Rudimentary voltaic piles and galvanic cells, usually zinc and copper submerged in acid, rapidly lost power because of decomposition of the electrolyte or deposition of hydrogen on the cathode. Longer-acting cells composed of two electrolyte solutions separated by a porous diaphragm were devised. Compact dry cells were taken on house calls. The electro-motive force of a single cell was approximately 1 volt, but up to 60 cells would be used in series (Fig. 4). Currents of between one and several hundred milliamperes were used.
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A Leyden jar discharges in the form of a rapidly oscillating spark. The electrical engineer Nikola Tesla (1856-1943) and the physician, physiologist, and physicist Jacques-Arsène d'Arsonval (1851-1940) independently used this principle in devising instruments that produced rapidly alternating (> 100,000 cycles/s) currents (Fig. 6A). Such high frequencies do not stimulate muscle contraction or nervous transmission; even large, high-voltage currents could be passed through a patient without inflicting discomfort or injury (Fig. 6B). Such currents were thought to enhance metabolism because they heated the tissues through which they passed.
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Technique
Sessions typically lasted from 10 to 30 minutes and were given daily or
several times weekly. Therapy continued for weeks or months until the disorder
was resolved or the patient tired of treatment. Care was taken to minimize
discomfort because patients were unlikely to return if the therapy was
painful.
Franklinism—A patient, seated on an insulated platform, received a static charge from an influence machine. The method of discharging the patient determined its effects. Sparks were drawn off by approaching the patient with a grounded electrode. The shape and composition of the electrode determined whether the discharge was in the form of painful sparks, a prickling brush discharge, or a soothing breeze of ionized air (Fig. 7). Rubbing the affected body part with an electrode wrapped in flannel produced an agreeably warm sensation. The static wave was a technique whereby the patient was rapidly discharged when a threshold charge was accumulated; muscles underlying the region in contact with the conductor contracted every few seconds on discharge. In the static bath technique, the acquired charge was allowed to escape the patient's body as a corona of ionized air; the sensation was that of a breeze. Certain disorders required a positive bath as a tonic or stimulant to restore the deficient subtle nerve fluid. A negative bath was thought to be hypostheniant and relaxing, and, therefore, useful for headache, neuralgia, and inflammation.
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Galvanism and faradism—The body surface is highly resistant to penetration by current. Duchenne pioneered the use of highly localized electrization when he showed that moistened sponges or leather pads facilitated transdermal passage of current. Muscles could be made to contract without injuring overlying skin. Closing, or making, a circuit near a motor nerve provoked contraction in the muscles it enervated; a weaker contraction occurred upon opening, or breaking, the circuit. No contractions were elicited by a continuous galvanic current, but an alternating faradic current was, in effect, constantly being made and broken, resulting in tetany. Sensations were induced when electrodes were applied over sensory nerves. Aberrant responses to electrical stimuli assisted in the diagnosis of disease states, indicating whether the lesion was central or peripheral, neurologic or muscular, physical or hysterical.
Central galvanization entailed the passage of a continuous current through the patient's body by applying a stabile, fixed cathode to the epigastrium while the labile, gliding, anode traversed the CNS from the cranium to the base of the spine (Fig. 8A). Alternatively, the patient's extremities were submerged in water baths through which a galvanic current was passed (Fig. 8B). Beard introduced general faradization, in which the patient was massaged with a sponge anode (Fig. 8C). Often, the operator became part of the circuit to better appreciate patient comfort.
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The negative electrode of a strong galvanic current causes tissue destruction, and the positive pole has a strong coagulative effect. Consequently, galvanic currents were used as an aid or alternative to surgery. Cataphoresis was the introduction of ionic medication through intact skin, driven by a similarly charged galvanic current.
Acceptance
Eventually, orthodox medicine accepted electrotherapy. Its popularity
peaked in the last decade of the 19th century when it was claimed that
"about ten thousand (U.S.) physicians...make use of electricity as a
therapeutical agent"
[42]. Several encyclopedic
texts were published [23,
42,
43]. An 1895 materia medica
devoted 70 pages to the subject
[44]. An 1894 survey found
that 67 U.S. medical colleges incorporated electrotherapeutics into their
curricula, and many had dedicated faculty and clinics
[45]. Postgraduate courses and
correspondence schools instructed practicing physicians. Manufacturers of
medical equipment offered electrostatic generators, medical batteries,
induction coils, meters, and applicators.
Electrotherapy specialists formed organizations to advance their discipline. The American Electro-Therapeutic Association (AETA) was incorporated in 1891. The Journal of the American Medical Association published the full proceedings of AETA's annual meetings, noting that their "papers showed scientific qualities unsurpassed in any other National organization" [46]. Electrotherapy had finally arrived.
Phototherapy
The therapeutic use of sunlight has ancient origins
[47]. Greek and Roman
physicians, including Hippocrates, Celsus, and Galen, prescribed
heliotherapy. But early Christian fathers associated sunbathing with
sun worship and suppressed it for almost two millennia. Solar deprivation was
common during the Industrial Revolution due to urban crowding and smog.
Rickets, scurvy, and scrofula became endemic in cities
[48]. Sunbathing was found to
reverse these disorders [49].
Focused sunlight was used to treat indolent skin ulcers in the late 18th
century [50]. Arnold Rikli
(1823-1906), the Swiss naturopath, established a sanatorium for hydrotherapy
and sunbathing in Slovenia in 1855. By the early 20th century, fresh air and
insolation, therapeutic sunbathing, became the cornerstones of
tuberculosis therapy.
Light in the violet end of the spectrum was found to have greater chemical properties, darkening silver chloride, than red or yellow light. Johann Wilhelm Ritter (1776-1810) discovered ultraviolet (UV) light in 1801. The carbon arc lamp, invented by Humphrey Davy (1778-1829) in 1802, was particularly rich in UV rays. In 1877, Downes and Blunt [51] showed that chemical rays, violet and UV light, were bactericidal. UV light continued to be used to treat cutaneous infections, such as erysipelas, until the advent of antimicrobials in the 1940s.
The peak of interest in phototherapy stemmed from the work of Niels Finsen (1860-1904). A native of the Faroe Islands and resident of Iceland and Copenhagen, Finsen attributed his chronic poor health to solar deprivation. Finsen investigated the use of chemical rays in the treatment of infection. He used the UV-rich output of carbon arc lamps because sunlight was scarce in Copenhagen. Recognizing that glass lenses filter UV light, Finsen focused the beams with quartz lenses. The heat-bearing red and yellow wavelengths were absorbed by the blue-tinted water circulating in the recess between lenses (Fig. 9A). The resultant concentrated, water-cooled UV light was first used to treat lupus vulgaris (cutaneous tuberculosis). Called the "wolf-cancer," victims of this dis-figuring infection became reclusive.
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Finsen reported on 454 cases of lupus vulgaris treated at his institute through 1899 [55]. Finsen light was also used to treat skin cancer, lupus erythematosus, luetic lesions, psoriasis, acne, rosacea, and fungal infections. He was awarded the Nobel Prize in medicine in 1903 for his achievements (Fig. 9B).
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Roentgen's first—and only—public presentation on January 23, 1896, featured a radiograph of a colleague's hand, suggesting a diagnostic use for the "new kind of rays" [56]. Finsen's work provided a rationale for the therapeutic application of X-rays. The necessary elements for the introduction of electromagnetic radiation into medical practice were in place at the close of the 19th century: equipment, expertise, acceptance, and rationale. The stage was set for radiology and radiation therapy.
Acknowledgments
The author wishes to acknowledge the technical advice provided by Jonathan
R. Tischler, doctoral candidate in electrical engineering, as well as the
assistance of Rosemary Leary and Andrew Dzaugis, Memorial Hospital
librarians.
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