This
year's Nobel Prize for Physiology or Medicine has been awarded by the Council
of Professors of the Caroline Institute to Professor Niels Finsen of Copenhagen
in recognition of his work on the treatment of diseases, and in particular the
treatment of lupus vulgaris by means of concentrated light rays.Finsen's studies in connection with this disease constitute the most well-known and the most fruitful part of his work and are responsible for the important role played by phototherapy in medical art today. His first steps in the field of phototherapy, however, were directed towards general biological problems related to the effects of light on the organism. This led him to consider a number of specific problems concerning the effects of light on the skin in certain diseases. At first his research was not concerned with lupus but with another disease, smallpox. This first project in the field of therapeutics was certainly far removed from the principles that Finsen followed later in the treatment of lupus and other diseases, but it prepared the way none the less for his major research in this latter field.
In 1893 Finsen recommended the use of red light in the treatment of smallpox; this treatment, by protecting the skin against harmful light rays, was believed to facilitate the healing of the skin lesions and prevent the appearance of scars which are often the sequel to this disease. An analogous form of treatment for smallpox had in fact been in use many years before and had even been current during a part of the nineteenth century. A firm basis for this practice was lacking however. The situation was far more favourable when Finsen began his research on the subject. In 1889 Widmark's important work had demonstrated that the most refrangible rays of the spectrum, in particular the ultraviolet rays, had a strong and specific effect on those parts of the body surface which were exposed to them. This effect is quite different from the irritations or bums produced by heat rays. At first no effect, or at the most a slight one, is apparent, but a few hours after exposure to the rays a certain degree of irritation is felt which progressively increases in intensity for about twenty-four hours and then gradually subsides. Finsen's proposed treatment of smallpox made use of Widmark's findings in this field. His method consisted in filtering off the ultraviolet rays by means of red glass and red curtains, etc., thus preventing their irritative effect on the affected skin, without having to keep the patient in total darkness.
Although this work brought recognition for Finsen, it is nevertheless of secondary importance when compared with the results of his further research. Finsen's stroke of genius in his later work was to attempt to make therapeutic use of the powerful biological effects of highly refrangible rays. In this way he blazed the trail for scientific phototherapy and for the curative use also of other rays than those contained in ordinary light.
Finsen's decision to follow this line of research was influenced by the phenomenon that light has the property of preventing the development of bacteria and even of killing micro-organisms. This phenomenon had already been observed in 1877 by Downes and Blunt and had been confirmed and studied by a number of scientists such as Duclaux, Roux, Buchner and others, on bacterial cultures, before Finsen undertook to apply it to living tissue containing bacteria. In this case also the active rays are the high-refraction rays of the spectrum. In considering the effects of light on living organisms containing bacteria, an explanation of the results obtained must take into account an essential factor other than the effect of light on pathogenic micro-organisms, namely, the already mentioned effects of light on the tissue itself. The question as to which of these two factors is most important in the therapeutic use of light will no doubt be the subject of further research. Whatever the answer may be to this question, the effective rays are the ones strongly refracted. The lower refraction rays, on the other hand, are of little use and, since they have the great disadvantage of producing combustion, must, as far as possible, be eliminated. Finsen's method is therefore in no way comparable to certain previous attempts to treat lupus by burning the affected tissue with a burning-glass.
The treatment of lupus by Finsen's method is carried out in the following way. Sunlight, or more frequently the light from a powerful electric-arc lamp (both forms containing a high proportion of active rays) is concentrated by means of lenses of appropriate composition into a beam from which the heat rays have been as far as possible eliminated; this beam is projected on a small area of affected skin, which has been drained of blood by pressure. The beam of light is applied continuously for one hour. Immediately afterwards the treated area becomes red and a little inflamed. During the next few days, this irritation of the skin increases, and then soon after begins to decrease and it is at this point that healing commences and scar tissue begins to form, which eventually produces a surface almost exactly like normal skin. Every part of the diseased area is treated consecutively, repeating the process twice on the same area if this proves necessary. This treatment has no unpleasant effects but it is expensive, requires constant supervision and considerable time. The results obtained, however, greatly outweigh these disadvantages. This method has proved of use in the treatment of a number of other skin diseases, but it has been particularly successful in the treatment of lupus vulgaris. None of the methods previously used for the treatment of this disease has produced results which can in any way be compared to those obtained with phototherapy.
Lupus vulgaris is, as we know, a form of tuberculosis, with localized lesions on the skin, especially that of the face, such as the nose, eyelids, lips and cheeks. The skin is gradually eroded, the face sometimes becomes dreadfully disfigured, and finally transforms patients into objects of repulsion. The chronic and progressive nature of this disease is particularly marked: it may remain active for ten years, twenty years, or even longer and, until now, it has proved resistant to all treatment. Even when patients had sufficient courage to persevere with these forms of treatment their hopes were dashed more often than not; rarely was a permanent improvement possible in this dreadful disease.
Thus it was that Finsen's method was hailed as a benefit to humanity when his treatment of lupus gave results which can without exaggeration be described as brilliant.
Finsen began to treat his first case of lupus in November 1895. Although the method had not yet been developed far, and although the case itself was of considerable severity, having proved resistant to all the current forms of treatment most energetically applied, the results were most satisfactory. News of this success soon spread: patients suffering from lupus left their hiding places and hurried from far and near to seek a cure or some relief from their suffering. They were rarely disappointed.
The new method soon obtained recognition from the medical world and became current practice. It also gained considerable support from philanthropists outside medical circles. The very next year, in 1896, the Finsen Institute of Phototherapy was founded in Copenhagen with funds obtained largely from generous private donations; the State and the City authorities also contributed. This Institute, devoted to research on the biological effects of light and the practical medical application of the results obtained, has since gradually been greatly developed and improved. It is now housed in its own recently equipped building, which includes a clinical section for the treatment of patients and an experimental research laboratory. It has a large staff including 8 doctors, 53 nurses, 3 assistants, other employees and numerous domestics.
Finsen's method for treating lupus is still used in the Institute. This year a report was published containing the cases of lupus treated during the first six years, up to and including November, 1901, in which 800 cases are described. The results are particularly satisfactory and are far superior to those obtained previously in the battle against this disease.
In 50% of these cases the skin disease was cured, although in many of them the lesions were extensive and of long standing. In a great number of cases, so much time has elapsed since the recovery that one considers this as permanent.
In the other 50% of thes cases, in which a complete cure was not achieved, a partial cure or a considerable improvement was obtained in most cases. In only a very small number of cases, approximately 5% of all cases, treatment was unsuccessful or produced only temporary results. From the beginning of December 1901 until the end of October of this year, 300 further cases of lupus were treated. It has been noted that in recent years the proportion of cases of early lupus is much higher than before. As Finsen has said, it seems that in Denmark the time will soon come when the last chronic cases of lupus will have disappeared. Since cases of early lupus respond more easily to treatment, the future is most encouraging.
This method represents an immense step forward and the work of Professor Finsen has led to developments in a field of medicine which can never be forgotten in the history of medicine. For this reason he deserves the eternal gratitude of suffering humanity.
