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where a stationary or cumbersome apparatus could be used. I will here give my personal observations on the use of this agent with records of cases treated in private practice.
That hot air is one of the oldest of therapeutic agents there can be no doubt, though it is only within a comparatively recent period that the intense heat now considered essential in its use, could te practicably applied by means of a portable apparatus. This object has at last been obtained through the perfection of mechanical contrivances for its use.
The Apparatus. In selecting an apparatus for private practice, portability with the ability to obtain the desired object (i. e., excessive heat without burning) must be the first consideration. For though in the warmer months “local baths" may be given in the office, this would hardly be advisable in freezing weather, for even the local bath produces profuse general perspiration and the susceptibility to cold is thus increased. Then a “general bath" in the office would be practically out of the question for obvious reasons.
In my experience "The Betz Dry Hot Air Apparatus,” being simple in construction, portable and efficient, has proved very satisfactory. It consists of an asbestos lined oven of galvanized iron, in which the limb is supported on a hammock. The flame does not come in contact with the interior, and the hot air is admitted through holes at the sides in the floor of the oven. The stand on which it rests with canvas appliances for treating leg, arm, shoulder, hip or back respectively, and gasolene burner and high temperature thermometer, completes the outfit. As it is put together in sections, it can be easily taken apart and carried from place to place. Gasolene will be found to be the most satisfactory method of heating, as it is inexpensive, easily regulated and can be always at hand. This apparatus, or one after this general plan, will also be found to be of service to the general practitioner a: a sterilizer, for dressings, bandages, etc. Fractional or complete sterilization by dry or moist heat (the latter by placing a basin of water on floor of the oven) may be accomplished by regulation of time and temperature, though of course without the more certain effects of steam under pressure.
METHOD OF APPLICATION Local Bath. The limb or part to be treated is wrapped in one or two thicknesses of Turkish toweling (depending on the susceptibility of the patient), snugly but not tightly applied. Special care must be observed in covering the bony prominences. The canvas extension is then fitted over the limb and the open end of the cylinder or oven-the limb being suspended in the hammock. The gasolene burner is started and the tenperature gradually raised to the desired point, usually 350 to 375 degrees F., though it is best to begin with a much lower temperature, 250 to 275 degrees F., as the patient is usually nervous and easily frightened at the first treatment. It should be held at this temperature for from forty-five to sixty minutes. It must be remembered that the temperature within the oven is not the actual temperature under the toweling, for when the thermometer there registers 375 degrees it will register a little below 275 degrees under one thickness of the toweling. In a case of a stiff joint or adhesions of tendons, massage and passive motion are at once practiced on removal from the oven. Otherwise, the part is dried with a coarse towel, rubbed with alcohol and handaged or covered for a time with flannel blankets.
The General Bath may be employed in one or two ways. The patient may be well wrapped in blankets, and an arm or a leg placed in the oven and raised to the temperature of the local bath, 350 to 375 degrees. Or the patient may be covered with a bath robe or blankets and a tent made of the bed clothes by half hoops placed over the body, and the open end of the cylinder introduced into this tent. The whole may then be covered with a rubber blanket.
In my experience I have found 180 to 200 degrees for one hour to be high enough for the general bath, (though it may be safely raised to 2750 to 300°) the head of course, remaining out. As this produces very profuse sweating I can see no indication for a higher temperature. After removing the heat the patients should be left rolled in the blankets for an hour, during which time they often sleep. Then they should be sponged with tepid water, rubbed dry with a coarse towel, well rubbed with alcohol and allowed to dress.
The Immediate Effect. (a) First stage or stage of congestion. A sense of intense congestion or swelling of the part, is experienced; the loose toweling seems a tight bandage; the part seems intensely hot, with almost a sensation of burning; the skin is almost scarlet, tense and dry. This stage is usually accompanied
by increased tension and frequency of the pulse, the pulsations of the arteries of the neck and the temples being plainly visible, face flushed, the impulse of the heart strong, even violent, with palpitation at times, especially with nervous women on beginning treatment. A throbbing headache is sometimes complained of. The bodily temperature is highest during this stage, usually jaised from one to five degrees, higher with the first than with subsequent treatments, showing, I believe, a certain nervous element. Such a patient will often complain that the part is burning, but if it is well and carefully wrapped, too much reliance need not be placed on this statement, for the sensation will disappear on the beginning of the sweating stage and will not be complained of after the first two or three treatments. I have never yet burned a patient and I have carried the temperature to 450 degrees, the part being covered with a double thickness of Turkish toweling.
(b) The Second or Sweating Stage begins after about fifteen minutes. The sense of congestion is at once relieved. Sweating, either general or local, is profuse. The tension of the pulse falls nearly or quite to normal; the temperature is from one to three degrees less than in the first stage; pain is at once relieved and there is almost a local anaesthesia of the part treated; a feeling of general comfort and drowsiness is experienced, and I, myself, have several times fallen asleep during treatment. Dryness of tongue and fauces with intense thirst frequently accompanies this stage. This sweating continues to the end of the bath, and if continued too long, at too high a temperature, or too frequently repeated, may considerably weaken the patient. The patients are allowed to drink ad libitum, during the bath, of cool water, or lithia water if indicated.
(c) On removal, the tissues are relaxed, skin moist and soft, pain relieved, and but slight if any tenderness where before it was marked. Oedematous or serious swelling is diminished and there is a healthy flush over the whole surface.
Remote Effect of Continued Treatment. Rheumatic attacks are cut short; serous or fibrous exudates are absorbed; pain is relieved; circulation is improved; there is reduction of local inflammation, and congestion of internal organs, especially of the kidneys. There is apparently slightly increased alkalinity of the blood (Na Cl and litmus test) and sweat the latter with first
treatment often being neutral or even slightly acid, later always strongly alkaline. The acidity of the urine is diminished.
Indications, in a General Way. (a) For local bath. Fibrous ankylosis or fibrous adhesions of joints or tendons, for absorbtion of serous effusions in joints or tissues, as serous synovitis, phlegmasia alba dolens, sprains, local ædemas, gonorrheal rheumatism, etc.; for relief of pain in sciatica, rheumatism, neuritis, etc.; to prevent or lessen inflammatory reaction after sprains, breaking of adhesions or injury to joints.
(6) For general bath. Any rheumatic affection, but especially the sub-acute and chronic articular forms; gout; chronic skin diseases; uræmia; passive congestion of the kidneys or suppression of urine from whatever cause; general cedema or moderate efiusion in serous cavities.
In the following records taken from my case book I will try to present cases representing as many separate indications as possible.
Case 1, Self. Diagnosis, chronic rheumatic arthritis of left knee joint of eight years standing. Its course had been characterized by acute exacerbations from time to time, during which relief was only afforded by fixation of the joint by means of splints or plaster of Paris casts, worn from four to six weeks. As a result of this treatment there were fibrous adhesions and inability to flex the joint beyond an angle of ninety degrees. The capsule of the joint was thickened, and uratic deposits formed about the ends of the bones. In spite of various forms of general and local treatment, acute exacerbations continued, until two years ago I decided that ankylosis in the extended position was the best I could hope for. The joint was fixed with plaster of Paris dressing changed every six weeks, for six months, at the end of which time there was complete fibrous ankylosis of the joint. At about this time I had an attack of sub-acute rheumatic synovitis of right knee with constantly increasing serous effusion. A cast was applied for six weeks, but at the end of that time there was no absorption of effusions from the joint. An attack of scarlet fever intervened, after which both knees were very tender and painful, so much so that any movement of them even to turn over in bed was very distressing. The “dry hot air bath” was then employed, one bath daily alternating right and left leg, the general bath being used about twice a week. Massage and passive motion followed at once on removal from the oven, and the faradic current was applied to the atrophied muscles. The snapping of adhesions in the left knee could often be heard across the room but was practically painless, and no inflammatory reaction followed. After six weeks treatment the pain, tenderness and effusion had disappeared from the right knee joint and the function was entirely restored. The left knee diminished one inch in circumference by absorp
tion of exudate, and could be flexed to an angle of forty-five degrees, and the tenderness which had always been present on the inner side of the joint was gone. After this, treatment was only employed as a prophylactic of acute exacerbations and though on several occasions such attacks have begun "in the old time style," from one to six baths have never failed to relieve every symptom and cut short the attack.
Citrate of lithia, five grains, three times a day, has been the only internal treatment.
Case 2, Mrs. J. F. Age 72. Diagnosis, fibrous adhesions of extensor tendons of the hand, resulting from Colles' fracture and use of anterior and posterior splints. I saw her one month after removal of the splints and the fingers could be but slightly Alexed. The adhesions were broken up and the hand at once placed in the hot air oven. No inflammatory reaction resulted. After one week's local treatment the patient was discharged as cured, having perfect flexion of wrist and fingers.
Case 3. Miss A. L. Age 45. Diagnosis, rheumatic neuritis of the uluar nerve of the left arm. The acute attacks, which usually occurred in damp or rainy weather or after exposure to cold, were characterize 1 by redness, swelling and tenderness along the course of the nerve whereever it became superficial. The pain was severe, radiating up the arm to the shoulder and breast of the same side. At these times the ring and little finger were slightly flexed. The patient was put upon salol and the "local hot air bath” was used daily for about six weeks. Temporary relief always followed its use, and the attacks have been less frequent and less severe of late. In this case I am now of the opinion that better results might have been obtained from use of the general bath.
Case 4. Mr. G. P. Age 72. Diagnosis, arthritis deformans of five years standing, involving both knee joints and the joints of both hands, with chronic nephritis and moderate cedema of both legs. The general bath was given, the knees being placed in the oven. The treatments were discontinued after one week, at which time he was able to walk farther with the help of his crutches and with less pain than he had for two years. The ædema entirely disappeared from the legs. This improvement of course was only temporary.
Case 5. Mr. H. B. Age 43. Diagnosis, sciatica, in which all the usual remedies had been tried without avail for six weeks. The local dry hot air bath was employed with result of immediate temporary relief of pain, and after one week's treatment all symptoms had disappeared and he was discharged as cured.
Case 6. Mrs. W. C. Age 29. Diagnosis, acute nephritis of pregnancy. I first saw her after she had been in labor forty-eight hours, and in the past twenty-four hours she had secreted about eight ounces of urine. A specimen examined contained a large amount of albumen and granular casts. There was moderate ædema of the legs and back, and a history of gastric disturbances extending over several weeks. Internal version was performed and the child at once delivered. Saline enemata, eight