G. Kahlmeter and A. Akerlund, Stockholm.

The roentgen treatment of arthritis.

The different forms of chronic arthritis are, I suppose, generally considered to belong, therapeutically, to the least grateful cases to treat. Even if by no means so hopeless as i t is said to be we are exceedingly glad of every additional therapeutic possibility.

The roenfgen treutmenf of urthritis seems to us to be a form of treatment well worth to be more extensively known and to be more utilized than appears to be the case a t present. True that this is no new form of treatment, as the first reports on attempts to treat arthritis by roentgen rays were already published as early as 1897 (by SOKELOW).~ However - as emphasized by nearly all who have in recent years related their experiences - it is surprising that this therapy has not become more generally employed, when realizing the really quite good results obtained by everybody who has tried it to any greater extent. There is no reason to hide the fact that THOR STENBECK, the Swedish roentgenologist, is mentioned almost everywhere in the literature as one of the first who employed roentgen treatment for arthritis. At the Northern Medical Congress in Kristiania in the year 18982 STENBECK reported 52 cases of articular rheumatism treated by roentgen rays and said he had obtained ))considerable improvement, in 40 per cent of the cases and sat least subjective improvement in another 40 per centu. He also refers to two significant clinical histories where swelling of the joint and pains had diminished considerably during the treatment, As a curiosity i t may be mentioned that one of us (AKERLUND) recently had the opportunity of seeing one of STEN- BECK’S cases, treated 31 years ago. This patient is now suffering

Fortschr. d. Rontgenstr. Published partly in the proceedings of the 2:nd Northern Medical

Bd. 1. p. 209.

Congress, partly in Fortschr. d. Rontgenstr. Bd. 2, p. 227.

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from severe chronic rheumatism, nearly all the joints being affected, but those least affected are the very joints, both knees and one of the elbow-joints, treated by STENBECK in 1897.

In the course of time a number of authors - some 30 in all - have subsequently published larger or smaller series of cases treated with roentgen rays. The greatest number of cases has been published by S T A U N I G ~ 1925 (400 cases) and by K R A U S ~ 1927 (285 cases). The results have as a rule been encouraging and most authors have found the roentgen treatment valuable in almost all forms of acute as well as chronic cases of arthritis. Quite parti- cularly good results have been obtained in gonorrheal arthritis, but also in subacute and chronic infectious arthritis, indeed even in genuine arthritis deformans, better results, according to several authors, can be obtained than by any other form of treatment. STAUNIG even maintains that there are few subjects in the whole field of roentgen therapy where the results are so certain and satisfactory as in arthritis.

The effect, exercised by the roentgen treatment on a diseased joint, shows itself in the first place in a diminution of the pains, those of spontaneous kind no less than the pain elicited on pressure and on movement. Furthermore, the mobility of the joint is as a rule increased, naturally just on account of the diminished pain- fulness but also because of the swelling, if present, of the capsule becoming reduced. The pain-reducing effect appears not rarely within a few days after commencement of treatment but the real improvement, in symptoms as well as signs, appears usually first a few weeks later. Several authors emphasize that improve- ment may be seen even several months after the last application of treatment. The more the pure inflammatory processes in the joints are in the foreground, the more rapid and better is as a rule the effect.

In what manner the roentgen ray treatment influences the arthritic processes is not clear. Most authorities consider the effect of purely local nature. One has imagined either a direct physico-chemical effect, an increased ionisation of the electrolytes of the cells and thereby facilitation of the process of electro-osmosis

Strahlentherapie 1925. a Med. Klinik 1917. p. 242.

Bd 20. p. 227.

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or else an effect like that obtained by ultra-violet rays, i.e. through skin irritation. Some authors regard the purely analgesic effect to be the main thing, others find that through disintegration of leucocytes fibrolytic ferments are set free, causing the inflammatory tissue to become *softened*. None of these theories has been proved and none of them appears to be particularly probable. I t would seem just as possible that the effect of the roentgen treatment might be of the same kind as that in the so-called non-specific irritation (shock-)therapy.

Since Professor GOSTA FORSSELL suggested to us to try roentgen treatment on the extensive material of arthritis a t hand a t As0 Hospital, we have been using this treatment for about three years in different cases of arthritis. The material is made up altogether of 94 patients with 180 joints treated. The greatest part of the cases have got no other treatment. The material includes arthritic cases of very different nature and etiology and different clinical types with patho-anatomical changes of very varying nature, from acute synovitis to destruction of cartilage and deformities. Even cases belonging to the same clinical group represent quite different stages of the disease, both from clinical and patho-anatomical aspect. The material should perhaps pre- ferably have been classified with reference to the patho-anatomical changes in the joints, as far as these can be ascertained on the radio- gram and a t the clinical examination. We have found i t impossible, however, to carry out such a classification, among other reasons because the different joints in the same case have fairly frequently shown patho-anatomical changes of considerably varying type and nature. We have, therefore, preferred to base our classifi- cation on clinical observations and made use of that usual a t Aso Hospital (a. KAHLMETER)~ which, on the whole, tallies with the up-to-date nomenclature in England and Germany [see e. g. ERNST FREUND: Gelenkerkrankungen, Berlin 19291.

The roentgenological technique employed in all the cases is, in the main, that generally used a t the present time in arthritis, that is to say, two or three series of treatment a t one or two months’ interval, each series consisting of a couple of deep roentgen doses

Described in greater detail In: rDe reumatiska sjukdomarnae h y Kahlmeter, Wahlstrorn L Widstrands forlag. Stockholm 1929.

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of medium strength applied from different aspects over the joint, one or a few days intervening between the applications.

STAUNIG, who perhaps has more experience than anybody on this subject, usually gives over each field on each occasion about 45 per cent H. E. D. through a filter of 0.36 mm. Znf2 mm. A1 a t a distance of 3 0 - 4 0 cm. He uses large fields of exposure up to 20x20 cm., irradiates from 3 directions during each series a t 7 days interval between the applications; after the first series he stops the treatment for 6 weeks, and after the second series 8 weeks. He does not give more than 3 series of treatment.

KADING who has submitted the last contribution to the roentgen treatment of arthritis in RStrahlentherapie,, 1926, gives doses of 15-35 per cent H. E. D. through a filter of 0.5 mm. Cu + 1 mm. A1 a t a distance of 27-35 cm. but in other respects follows the plan laid down by STAUNIG.

We have made use of much smaller fields than STAUNIG, so that, for instance, in the treatment of knees we have obtained 4 fields round the joint without the limits overlapping. In the treatment of a knee or an elbow the breadth of the field has been taken equal t o l /* of the circumference of the joint and the height of the field 15 cm. In the first series two opposite fields have been irradiated generally from the outer and inner side on consecutive days, the next series, after an interval of 4-6 weeks from the remaining aspects - from the front and behind - the third series [which, nearly without exception, has been the last one] after an interval of another 4 4 weeks again from the outer and inner aspect. Over each field has each time been applied 25-33 per cent H. E. D. through a filter of 0.5 mm. Cu + 1 mm. Al, 170 KV and a t a focal distance of 30 cm. The shoulder- and hip-joints have been irradiated from 3 fields (in front, from without and from behind), otherwise as for the knee- and elbow joints. The small joints of hands and feet have usually been irradiated from altogether two fields and for these small joints a filter of 4 mm. A1 has been used insted of Cu, besides the doses having been somewhat larger.

Similar to STAUNIG we have noticed no alteration of the skin after roentgen treatment but some slight pigmentation.

The results have been summarised in the following table.

23

Free from Unim- Cases Joints symptoms Improved proved I. Chronic infectious arthritis

orRlieumatoid arthr. (6 men. 28 worn.). 34 88 10 65 13 . . . . . . . .

~~

I1 s. Endocrinic-diatetic polyarthr,

I1 b. Isolated omarthritis (1 men,

I1 c. Acromio-clavicular arthritis

(7 women). . . . . . . . 7 15 0 10 5

5 women). . . . . , . . . 9 10 5 5 0

(5 men, 6 women) . . . . . 14 11 7 7 0

a) genum (2 men. 11 vomen) 13 25 7 16 % b) coxae (2 men, 8 women). 10 14 0 5 9

111. DMonarthritis, deformans

IV. Gonorrheal arthritis . . . . 5 6 6 0 0

V. Monarthritis(synovitis)intbc. 3 3 2 1 0

staue. . . . . . . . . . . 2 5 5 0 0 VI. Articular gout in subacute

Total 94 180 42 109 29 (23 O/o) (60 Ole) (17 O / o )

The largest group is made up of *chronic infectious arthritisu [rheuma- toid arthritis], including in the first place such cases that are often called usecondary chronic, and also such primarily chronic cases where the history (periods of subfebrile temperature) or the clinical examination [rise of temperature, anaemia, leucocytosis, marked increase of the sedimentation rate, valvular defects etc.] indicates that the etiology is probably to be found in some infection.

This group comprises 34 cases [ G men and 28 women) with an aggre- gate number of 88 joints. Of these 88 joints 10 [or 11.4 per cent] have been rendered free from symptoms, 65 [or 73.8 per cent] clearly improved, subjectively as well as objectively, while 13 [or 14.8 per cent] have re- mained on the whole the same.

The second group comprises 3 types of arthritis which do not belong to the group of primary osteoarthritis deformans; neither, however, do they give any evidence of any infectious etiology but are probably con- nected with changes in the metabolism or in the endocrinic glands. The first sub-group, uendocrinic-diatetic poly-arthritis*, corresponds best wit UMBER’S Pperiarthritis destruenso. I t comprises 7 cases, all women, with 15 joints treated, of which none was rendered free from symptoms but 10 improved and 5 remained unaffected.

The group of isolated omarthritis clinically characterised by restricted movements in one or both shoulder-joints without demonstrable roent- genological changes in these, the acromio-clavicular joint, the bursae or the soft parts around the joint, and by the fact that no other joints in the body are affected, is represented by 9 cases (4 men and 5 women) with 10 treated joints. Half the number has been rendered free from symptoms and. the other half considerably improved.

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Exactly the same result has been obtained in arthritis of the acromio- clavicular joint. These cases, characterised by a distinct tenderness on pressure over the joint and pains on abduction of the arm but not on ro- tation and besides, as a rule, by roentgenologically demonstrable changes [foci of sub-chondral absorption etc.], occur partly in the form of an iso- lated arthritis, partly as part of a polyarthritis, and are in our opinion clinically well defined.

I t may be mentioned in passing that a condition of exceedingly common occurrence in this region (shoulder-joint) but which is no proper arthritis, namely the so-called bursitis calculosa or, as i t is now generally called in Sweden, peritendinitis calcificans, reacts extremely well to roentgen rays. The calcified shadQws visible on the radiogram in the soft parts close to the tendinous insertions on the greater and lesser tuberosities disappear almost without exception under roentgen treatment at the same time as the pains and the restricted mobility become reduced. We have had the opportunity of together seeing some 50 cases of that nature which nearly all of them have been rendered quite free from both symptoms and signs without any other treatment.

Of typical *primary* arthritis* or osteoarthropathia, deformans we have treated 23 cases (36 articulations). In 13 cases (25 joints) i t was a question of the knee-joints (most of them post-traumatic arthritis defor- mans), in 10 cases (14 joints) malum coxae senile. Of the knee-joints 7 became free from symptoms and 16 improved (i. e. the majority of them) and 2 only remained unaffected; of the hip-joints none got rid of their symptoms, 5 - about l/s- improved and 9 - - remained unchanged.

The next group, gonorrheal arthritis, (5 cases, 6 joints) shows ercee- dingly good results. Two of these were very recent cases with marked periarticular oedema, violent pains and high temperature. The effect of the roentgen treatment in these cases gave almost the impression of won- juringn. After very few days all symptoms and signs were nearly gone altogether. In several cases the effect was more rapid than that seen after gonargin injections. A couple of cases have only been treated in a later stage of the disease [after the arthritis had been present for some weeks]. Here, too, the effect was excellent.

Group V comprises 3 cases of synovitis in solitary joints of individuals suffering from pulmonary tuberculosis but with negative guinea-pig tests from puncture of the joint. Two of these became free from symptoms and the third improved considerably.

The last group comprises 2 cases of certain gout, arthritis urica Vera in subacute, #drawn-outr stage where medicinal and phyerical treatment had brought about no appreciable improvement. All the 5 cases treated became rapidly free from signs as well as symptoms.

Our cases are, of course, not very many and some of the clinical groups, into which they have been classified, only include a few cases, On the other hand, we believe it to be of some value to

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make such a classification (which has not, as a rule, been done by previous authors) as a priori considerably varying results are to be expected in different clinical forms of arthritis. In conformity with previous experience, we have had quite excellent results in gonorrheal arthritis. In these cases roentgen treatment is probably the best method of all, We have also had excellent results in cases of subacute gouty arthritis, in ))isolatedu omarthritis and in the fairly common and important cases of arthritis in the acromio- clavicular joints. True, our cases of these forms of arthritis are not very many, but the results are clearly encouraging and these forms of arthritis have not been mentioned in earlier publications on this subject.

The most common forms of chrqnic arthritis, rheumatoid ar- thritis and arthritis or osteoarthropathia deformans, make up also among our cases the largest groups. The results we have obtained from the roentgen treatment in these forms of arthritis correspond with previous experience, i. e. they must be said to be good, indeed surprisingly good, if due consideration be paid to the clinical forms present and the patho-anatomical changes we are dealing with here. The majority of patients have been very pleased with the treatment and delighted with the effect they seem to have noticed, and quite infrequently i t has happened that patients have been exceedingly disappointed when we have been unable to fall in with their wish to continue a treatment they seem to derive so much benefit from; the risk of late damage to the skin, however, has deterred us from giving larger doses than those mentioned in our description of the technique. This fact of being unable, unreservedly, to continue with a therapy that has ameliorated the symptoms of the patient and which has given him the impres- sion of considerable improvement of his condition, has frequently marred the satisfaction we otherwise should have felt in our attempts with roentgenological treatment of arthritic cases. Pos- sibly modifications of the treatment might be found in the future, bringing with them still further improvements in the results, but already now the roentgen therapy seems to us to well defend its place in the treatment of many different forms of diseases of the joints.

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Discussion ,

BJURE. - For about a year I have rather extensively prescribed roentgen-treatment for articular rheumatism. So far 88 patients have under- gone this treatment. The procedure has been the same as that indicated by Dr. KAHLMETER. The results agree rather well with his. The roentgen-treatment has been given by Dr. RUNSTROEM.

Among the 88 patients 66 have suffered from chronic polyarthritis, into which group I have brought together the so-called primarily and secondarily chronic cases, 6 of malum coxae, 9 of arthritis deformans genuum, 11 of spondylitis deformans and 2 of arthritis gonorrhoica.

As, however, most of the patients had undergone other treatment as well as roentgen-treatment, such as bath, massage, diathermy, etr., it, was sometimes very difficult to establish with certainty the actual cause of the improvement. For this reason I have considered only those as definitely improved by the roentgen-treatment whose improvement was directly connected with this. I t is remarkable how often the roentgen- treatment has very rapidly brought about a striking effect, the patients having during the next day or days themselves indicated that the pains and tenderness especially had considerably lessened. Yet sometimes a certain reaction in the form of increasing pains in the joints seems to appear immediately after the treatment, but in a few days this deteriora- tion is generally followed by a conspicuous improvement. Sometimes the improvement passes away rather quickly, after a few weeks. In that case i t is advisable to repeat the roentgen-treatment after a few weeks.

The result of the roentgen-treatment has been as follows: of 66 cases of chronic polyarthritis 30 were positively improved, 19 probably, while 17 cases were not influenced a t all. For arthritis deformans genuum the corresponding numbers are 4,2 and 3, for malum coxae 2, 3 and 1, for spondylitis deformans 3,3 and 5. Out of 2 cases with gonorrheal arthritis one has grown much better and one somewhat better. The percentages of those cases positively improved are

for chronic polyarthritis . . . . . . . . . . 45.5 % o arthritis deformans genuum . . 44.4 yo H malum coxae., ................ 33.3 yo

Although the number of cases, especially in the 3 last groups, is very small, I should think that these percentages are quite reliable or at least not too high. The best result, then, has been obtained in the cases of chronic polyarthritis and the arthritis deformans genuum, the lowest one in the case of spondylitis deformans.

The effect of the roentgen-treatment on articular rheumatism, is not, indeed, as good as on sciatica, where I obtained a considerable improvement or absence of symptoms in 7 cases out of 10, thus in 70 Yo; but, nevertheless, it is surprisingly favourable. I t is surely not inferior to

)) spondylitis deformans ........ 27.3 yo

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any other method of treatment as t o its efficacy, where solitary joints and chronic articular rheumatism are concerned. No, indeed, I think there are good reasons for the affirmation that the roentgen-treatment is decidedly the very best one we have. This is supported by the fact that many of the cases improved by means of the roentgen-treatment had proved entirely refractory t o any other treatment.

KAHLMETER. - I can agree with Dr BRAHME when he says that the improvement, as a rule, sets in as early as after the first series of treatments, if there be any improvement a t all. At the Aso hospital we now proceed in this way that, if no improvement is seen after the second series, we give no third series. If after the first series no improvement appears, we proceed differently in different cases, according to the clinical features of the case and the patient’s own desire. Sometimes, however, the effect appears as late as after the second series, but hardly ever later. On the other hand,it rather frequently happens tha t after a good effect after the first series the second and third series also bring about a continually increasing improvement.

As to the spondylitis deformans mentioned by Dr. BRAHME, I have had no such case for treatment.

However, I have treated some cases of Spondyl-arthritis anchylopoe- tica (Striimpellmarie) and the effect on the frequently very annoying pains in the cervical and dorsal regien of the spinal column, connected with this disease, is a most evident one.

SCHOTT. - Treatment of the gonorrhaeic Arthritis: During my three years assistantship at the venerologic section of the Saint George’s Hospital a t Stockholm I have seen favourable results from intravenous gonargine- injections, if large doses were used (2 millions and more) and a high fever was obtained (41’ C ) .

In one case there was a joint which was the seat of a gumma. The patient had formerly suffered from acute arthritis. In the genitalia no gono-cocci were found during the s tay a t the hospital. The lues-treatment had led to the disappearance of the gumma. The joint was still swollen. In order to know, if tubercle was at hand, the joint was punctured, and in the exudation I found gonococclike diplococci, which, when cultured, behaved as gonococci. This explained, why neo-salvarsan and salicyl- treatment did not give the effect desired.

Although the gonargine-treatment is rather disagreeable to the patients on account of the severe shivering-fits, they prefer this treatment to any other. To a feeble heart however, i t is dangerous. Further I remember having observed once tha t in a patient a thrombus in the deep veins of the lower extremities, which owing to a strong joint-swelling was not diagnosed, loosened during the enormous fever-shiverings and led to exitus.

I have described a case of acute arthritis in the Svenska Lakaretid- ningen (Swedish Medical News) N. 2, 1928. I t occurred in a patient who for

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economic reasons refused to be taken under hospital treatment. I was asked to treat him. He had enormous effusions alternately in several joints. Little by little he became so much better that he was able to walk, although with difficulty. After some time he came to me and showed me that his joints were functioning perfectly well. He thought the improvement was due to the use of so-called *Russian fungusn (nVolga fungusr). This he had obtained through an acquaintance of his from Copenhagen. From the ufungusr he made tea, which he drank in the course of the day (about 2 drinking-glasses). In all he had consumed about 75 kg. of tea. I have examined the rfunguse bacteriologically. I t is chiefly composed of a rpoly- morphous leaven-celle. Different afungus-cultures, are not identical. The rfungus-massn contains a varying number of bacteria. Different kinds of sordes are also to be found in the cultures. 1 have coloured scratch- compounds from these and I have caused a series of incisions to be per- formed and these to be coloured. The fungus-tea is prepared by throwing a faint solution of sugar on the fungus-mass. After 24 hours the tea is poured out and drunk. I t is more or less sour and contains a little alcohol. I t is said that there is also in the liquor a certain number of enzyms, a D- vitamine and some acids belonging to the group of the anti-rheumatic medicines. This popular medicine is used in all secrecy by many sick persons for all kinds of complaints and also by sound persons, in order to protect them, as it is said, against diseases. I t counteracts constipation and seems to regulate the evacuation. By examining the faeces of the patient I came to the conclusion that i t influences the intestinal flore. The belief in the rfungus tear is also probably a factor of importance. On the prescription of a physician I have given the ,fungus culturer gratui- tously to patients for the prevention of different complaints. Thus a case of gout, which had defied authoritative treatment during a stay a t a spa abroad became by the use of fungus-tea free from symptoms. The popular medicine may have found in this case a means that is sometimes capable of influencing certain joint-complaints or preventing their origination.

BRAHME. - The great majority (300-400 cases) of articular diseases, treated a t the NorrkOping Hospital were not treated exclusively with roentgen, therefore i t is somewhat difficult t o judge the result. On the whole, however, I have the same impression as Dr KAHLMETER, i. e. that roentgen is one of our strongest weapons in the treatment of this disease. The same is true, as Mr. KAHLMETER has pointed out, of the spondyl- arthritis anchylo-poetica. Anyhow it is advisable to reckon with the risk of anaemia arising eventually, a t least in the treatment of a plurality of joints; during a poly-articular treatment examinations of the blood should be made. If the treatment during the time immediately after the first treatment has not brought any subjective improvement, a continued treatment does not, as a rule, lead to any positive result. This is much more decidedly true of a second series of treatments.