Presented by Mrs. Hunter COLLEGE OF OSTEOPATHIC PHYSICIANS AND SURGEONS LOS ANGELES, CALIFORNIA THERAPEUTICS OF DRY HOT AIR BY CLARENCE EDWARD SKINNER, M. D., LL D. Physician in Charge of the Newhope Private Sanitarium, New Haven, Conn. ; Editor of the Archives of Physiological Therapy ; Formerly Professor of Thermotherapy at the New York School of Physical Therapeutics ; Member of the American Medical Association, American Electro- Therapeutic Association, American Roentgen Ray Society, American Association for the Advancement of Science, Yale Medical Alumni Association, Connecticut Medi- cal Association, New Haven County Medical Society ; Associate Fellow New York Academy of Medicine ; Foreign Mem- ber Societe Franjaise d'Electro- therapie et de Radiologie, etc. SECOND EDITION ENLARGED AND THOROUGHLY REVISED NEW YORK A. L. CHATTERTON & CO. PUBLISHERS GOB 465" COPYRIGHT, 1907, BY CLARENCE EDWARD SKINNER. DEDICATED TO THE MEMORY OF THE LATE DR. HEMAN BANGS SMITH, WHOSE PERSONALITY, RICH IN THE UNCONSCIOUS NOBILITY OF TRUE MANHOOD, AND OVERFLOWING WITH THE MILK OF HUMAN- KINDNESS, WILL ALWAYS BE RECALLED WITH DEEP AFFECTION BY THE AUTHOR. PREFACE TO SECOND EDITION. FOR several years past the writer has felt that new forces were coming to the front in the therapeutical world, that were destined in a few years to revolutionize the current methods of treating many disease processes and to greatly increase the inherent efficacy of others; we refer to the so-called "physio- logical " forces, heat, cold, electricity, the various forms of radiant energy, etc. The first edition of this book was written for the purpose of bringing before the profession one of these forces which the writer's experience had convinced him was destined to become one of the foremost in therapeutical im- portance and utility, and which was known and understood by but a very small number of medical men. The conviction that a book upon dry hot air would fill an urgent want has been fully confirmed by the manner in which the first edition was received and which has encouraged the author to omit no pains in order that this, the second edition, shall be complete in every respect. Although the general plan and scope of the work, as em- bodied in the first edition, remain the same, yet the addition of matter pertaining to many small but important details, and several illustrations which were needed for complete elucida- tion of the text, has increased somewhat the size of the volume ; as the subject-matter has been entirely rewritten and rear- ranged, however, this increase in size does not interfere with accessibility to the contents, and accessibility is still further facilitated by the exhaustive character of the table of contents and the index. The plan of mentioning briefly the other remedial measures which it is advantageous to employ in conjunction with dry hot air, has also been retained. As stated in the preface to the first edition, this agent " is not an universal panacea. It is simply a rational therapeutic element which, alone or in combination 27043 vi Preface to Second Edition. with other remedial agents, will increase greatly our power to overcome pathological processes. In order to appreciate its true value, therefore, it must be viewed in its various thera- peutical relations, not alone." At the suggestion of many who have perused the first edi- tion, a number of additional case reports have been introduced to illustrate and demonstrate statements made in the text. The results obtainable with dry hot air are sometimes so magical as to tax uninstructed credulity to the utmost, hence these illustrative cases have been selected, as far as possible, from among those patients who are now alive and accessible ; there is no evidence so convincing as that furnished by one's own senses. His experience, since the first edition was published, has not led the author to change his opinions on any of the cardinal principles theiun set forth, but has resulted, as suggested above, in some amplification and development of those princi- ples : the description of these contained herein he believes adds greatly to the value of the present edition as compared with the previous one. He desires hereby to thank those who have by apt sugges- tion assisted him in bringing the work to its present degree of usefulness, and to express the hope that this volume will be as helpful to his colleagues in the future as he has been many times informed the previous one has been in the past. C. E. S. NEW HAVEN, CONN., March, 1905. PREFACE TO FIRST EDITION. DRY superheated air as a therapeutical measure has now been before the medical profession for several years, yet as far as the average practitioner is concerned it is still a new and un- known quantity. Even the latest text-books dismiss it with but a mention, and that only in connection with two or three pathological processes. This general ignorance of the agent is to be deplored, as, when skillfully administered, it is one of the most potent and useful at our command and applicable to many disease conditions wherein the ordinary methods of treatment are unsatisfactory. In the following pages is set forth what has been ascertained in reference to dry hot air therapeusis up to the present time. It has been considered desirable to mention briefly the other remedial measures which it is advantageous to apply to differ- ent conditions in combination with dry hot air, because this agent is not an universal panacea. It is simply a rational thera- peutic element which, alone or in combination with other rem- edial agents, will increase greatly our power to overcome patho- logical processes. In order to appreciate its true value, there- fore, it must be viewed in its various therapeutical relations, not alone. Where necessary to elucidate the manner in which dry hot air produces its effects, the pathological features in- volved in the condition under consideration have been briefly noted. Many of the failures to secure satisfactory results with dry hot air have been due to the fact that it has been called upon to influence pathological conditions which were not amenable to its physiological action; others more numerous still have been due to faulty technique in its administration. These sub- jects, therefore, have been treated at some length. It is not to be expected that every general practitioner will or can become a dry hot air expert, but every physician should at viii Preface to First Edition. least understand the principles of its application and the'clinical results derivable therefrom, in order that he may be able to decide intelligently when his patient will be benefited by its use. If he does not care to undertake its actual administration he can send his patient to someone who is an expert. Finally, too much must not be expected of dry hot air, or any other one measure. It will, alone and unaided, cure some disease conditions; others will require all the therapeutical resources at our command; and in still others even all that we have will not suffice to produce a cure. Its powers, how- ever, are exerted in directions in which remedial agents hith- erto known have been very deficient; its addition to the treatment results in benefit to many patients who would fail to improve under other measures alone, and its adoption into our armamentarium enables us to increase by a large percent- age the sum total of our power over disease. Any agent ppssessing these attributes is entitled to respect and study. Dry hot air exhibits them in an eminent degree. CLARENCE EDWARD SKINNER. NEW HAVEN, CONN., October, 1902. CONTENTS. CHAPTER I. APPARATUS. PAGE Outfit . . . ; . . i Construction i THE BODY APPARATUS 2 Structural Modification of Body Apparatus, . . . .2 THE GENERAL LOCAL APPARATUS, 12 THE KNEE APPARATUS . 13 Internal distribution of heat .' ; 13 Elimination of moisture, . . . . . ... . [4 Fire-proof cloth fittings, '.'. . *~ ' 15 Source of heat, . . 16 Special chair for local application to shoulder, . ... \~j Location of apparatus, . . . ^ . . . . .18 DEVICES FOR APPLYING DRY HOT AIR TO THE OPEN CAVITIES OF THE BODY 18 External auditory canal,. . . . . . . .19 The alcohol heater, 19 The gas heater . .20 The electric heater , . 21 CHAPTER II. PHYSIOLOGICAL ACTION. Differentiation from other methods of administering heat, . . 23 Electric arc and incandescent light baths. . . . . -23 Hydrotherapy, . . . . . . . . -24 Varieties of application and nomenclature, 25 GENERAL APPLICATION, 25 Body temperature, ......... 25 Pulse, 25 Respiration, . . . . . . . . . .25 Skin 26 Blood, 26 Urine 26 Variations in extent of influence induced, .... 26 ; Contents. PAGE Subjective phenomena, ........ 27 Rationale of action, ........ 27 Sphere of action, 28 LOCAL APPLICATION 28 Elements of physiological action, .... .28 Temperature elevation of part treated, 28 Reflex effects, 29 General body temperature and pulse, 30 Sphere of action, 3 Summary of Physiological Influences, ..... 30 General application, ........ 3 Local application, ........ 3 1 Clinical applicability, 31 Analogies, . 3 2 Fallacies, . 32 As to identity of the influences exerted by hot and cold appli- cations, .......... 3 2 As to identity of the effects producible with dry hot air and hydrotherapy, 37 As to the rationale of its physiological influences, ... 39 As to permanence of results, 40 CHAPTER III. TECHNIQUE. Methods of preparation, 42 LOCAL APPLICATION -43 Preparation 43 Arms and legs 43 Knee, . 44 Shouklei , 56 Hip, 57 Abdomen, 57 Chest wall and lumbar region, ...... 57 Amount of wrapping necessary, ...... 58 Apparatus, . .58 Administration, ......... 58 Duration and Intensity of se'ance, 75 After-care, . . . . . . . . . -75 External Auditory Canal 75 Management of the apparatus, 75 Preparation of the patient, 76 Contents. xi PAGE Administration, 75, GENERAL APPLICATION, '. 76 Preparation 76 Administration, 7- Prevention of accidents, 81 Intensity and duration of seance 83 After-care, ........ 8c In Genera], Frequency of administration 86 Intermissions in treatment, . .... 86 Burns 87 Contra-indications 87 Atheroma and irregular pulse, .... 88 Valvular heart lesions, 88 Pyrexia 88 Hyper-pyrexia ^ Local infective or inflammatory foci, ox> CHAPTER IV. SPRAINS. Modifications of Clinical Conditions producible with Dry Hot Air, 92 Local Application o 2 General Application 02 Rationale of Thermotherapy 02 Pathology and Symptomatology, 93 Therapeutic indications, 02 Local application, g z General application o. Illustrative Case 04 Treatment, Q , Local dry hot air application 0,4 General dry hot air application, or Additional remedial measures oc CHAPTER V. RHEUMATISM. Modifications of Clinical Conditions producible with Dry Hot Air, 97 Local Application, 97 General Application 97 Rationale of Thermotherapy yj Etiology, pathology, and symptomatology, ..... xii Contents. PAGE Therapeutic indications 99 Local application 99 Is salicylic acid a specific for rheumatism ? 101 General application, . . . . . . . . .105 Diagnosis, . . 105 Illustrative Case's, 106 Acute rheumatism .106 Chronic rheumatism. . . . . . . . .109 Treatment, . . . . . . . . . . 1 10 Clinical forms of rheumatism, i 10 Complications, . . . . . . . . .ill Local dry hot air application, . . . . . . . i 1 1 After-care, . . .112 General dry hot air application, .112 Additional remedial measures 113 Diet 113 Drugs 113 Aspirin, 113 Salicin, 114 Sodium salicylate, . i 14 Salophen, 114 Methyl salicylate, ' . . .114 Alkalies, . ....... . . i 14 Salines, . . . . . . . . . .115 Electricity, . -115 The static current, . 115 The magnetic-induced current 115 The Voltaic current, . 115 Chronic rheumatism, .'.*.. 1 16 Treatment, i ( 6 CHAPTER VI. LOCAL SEPTIC INFECTION. Modifications of Clinical Conditions producible with Dry Hot Air, 117 Local Application, ... 117 General Application, ... 117 Rationale of Thermotherapy, i r g Etiology and pathology, ... i [8 Therapeutic indications, . , m Local application ,, 9 General application, . , 2I Illustrative Cases, . I22 Contents. xiii PAGE Treatment, .126 Local dry hot air application, ." . . . '" . . .126 General dry hot air application, 127 Additional remedial measures 128 Diet 128 Drugs, . . ... 128 Operative interference, 128 Electricity 128 CHAPTER VII. PNEUMONIA. Modifications of Clinical Conditions producible with Dry Hot Air, 130 Local Application, 130 General Application, . . 130 Rationale of Thermotherapy 131 Etiology and pathology, . 131 Therapeutic indications . .134 Local application, -.--. . . . . . . 135 General application, ......... 138 Illustrative Cases, . . 138 Treatment, ........... 144 Local dry hot air application 144 After-care, 144 General application, . . . . . . . . . 147 Heart failure, 148 Additional remedial measures, . . . . . . .148 Drugs, . . . 148 CHAPTER VIII. ALBUMINURIC NEPHRITIS (BRIGHT'S DISEASE). Modifications of Clinical Conditions producible with Dry Hot Air, 150 Local Application, 150 General Application, . . . . . . . . . 1 50 Rationale of Thermotherapy 150 Etiology, 150 Symptomatology and pathology . .151 Nature of specific toxin, 153 Therapeutic indications . .156 General application, . . 157 Illustrative Cases 157 Treatment, 166 xiv Contents. PAGE General dry hot air application, . . . .... . 166 Additional remedial measures, ....... 167 Diet, .167 Clothing, 167 Drugs, ... . . 167 Electricity 167 CHAPTER IX. ARTHRITIS DEFORMANS. Modifications of Clinical Conditions producible with Dry Hot Air, 169 Local Application, ......... 169 General Application, 169 Rationale of Thermotherapy, . . . . . . .169 Etiology and pathology, . . . . . . . .170 Neural theory, . . . . . . . . .170 Rheumatism as a causative factor, . . . . .172 Symptomatology, . .173 Pain .173 Body temperature, 174 Nervous system, . . . . . . . . .174 Muscular atrophy, 173 Muscular spasm, ......... 175 Skin 175 Albuminuria, . .176 Joint appearances, . . . . . .- . . .176 Diagnosis 177 Symptomatology, . . . . . . . . .177 The Roentgen ray, . . . . . . . ... 178 Inconstancy of symptom complex, . . . . . . 181 Therapeutic indications, . .182 Local application, .182 General application, . . . . . . . . .182 Illustrative Cases 183 Treatment, 188 Local dry hot air application, . . . ... . .188 General dry hot air application, . . . . ... 189 Additional remedial measures, . . . . . . .190 Electricity, .190 The static current, . . . . . . . 190 D'Arsonvalization, ........ 191 The continuous current, ....... 191 Magnetic-induced current, . . . . . . 192 Mechanical vibratory stimulation 192 Contents. xv PAGE Massage, 193 Diet 193. Clothing. 193. Drugs, . 194. Alteratives and tonics, . . . . . .194. The salicylates, . . . . . . . . .194. Laxatives, . . . . . . . . . '95 Digestants 19^ Pain-relieving agents, 195 Management of affected joints, 196 Routine treatment, . . . . . . . . .196 Relapses, . 198 CHAPTER X. PERITONITIS; PLEURITIS; SYNOVITIS; NEURITIS AND SCIATICA; LITH^EMIA AND GOUT; NEURALGIA AND MYALGIA ; VARICOSE ULCERS ; OTITIS. Peritonitis, 200 Varieties, ........... 200 Sphere of usefulness of dry hot air, ...... 200 Illustrative Case, . . . . . . . . . 202 Treatment, ........... 206 Local dry hot air application, . 206 General dry hot air application, 206 Additional remedial measures, 206 Pleuritis 211 Varieties, . .211 Sphere of usefulness of dry hot air, . . . . .211 Treatment, . . . . . . . . . . .212 Local dry hot air application, . 212 General dry hot air application, . . . . . .212 Additional remedial measures, 213, Synovitis, . . . . . . . . . . .213 Varieties . .213 Sphere of usefulness of dry hot aii , ...... 213 Treatment, 21 5. Local dry hot air application 215. After-care 215 General dry hot air application, 216 Additional remedial measures. . . . . . .216 Neuritis, 217 xvi Contents. PAGE Etiology, . . . . . 2I 7 Treatment, . . . "...-. . . . .217 Dry hot air, . 217 Additional remedial measures, 218 Electricity, - . . . . 218 Diet, . . . .218 Drugs, ... . 218 Physiological rest 219 Sciatica, ............ 219 Causation and pathology 219 Sphere of usefulness of dry hot air 219 Illustrative Case, . . . . . . . . . 220 Treatment, . . . . . 221 Sciatic rheumatism, 221 Sciatic neuritis, . . . . . . . . . 222 Electricity, . . . . . . . ' . . . 222 Mechanical vibratory stimulation, . . . ... 223 Immobilization, 224 Operative interference, 224 Lithaemia, . . \ , 224 Definition of term, . . . . . . . . . . 224 Etiology, pathology, and clinical characteristics, . . . 224 Therapeutic indications, 226 Treatment, ........ . 226 Diet, . ..... . . . . . 226 General dry hot air application, 226 Electricity and hydrotherapy, 227 Drugs, . 227 Exercise, . 227 Gout, . . . 227 Neuralgia, ..'.... 228 Treatment, . 229 General dry hot air application, 229 Local dry hot air application, ....... 229 Electricity, .......... 230 Drugs, 230 Myalgia 230 Varicose Ulcers, 231 Treatment, 231 Local dry hot air applications, . . 231 General dry hot air applications, 231 Electricity . .231 Contents. xvii PAGE Drugs and surgical dressings, ... ... 232 Otitis, ... . . . 232 CHAPTER XI. MISCELLANEOUS CONDITIONS. Nervous Debility and Exhaustion, 236 General debility and the convalescent state, . . . . 236 Pulmonary tuberculosis, . . . . . . . . . 238 Chronic bronchitis, . . . . . . . . . 241 Fibrous anchylosis, 241 Cholelithiasis, . . . 242 Gangrene, . . . . . 244 Angina pectoris, . % . . .'.... . 245 La grippe, . . . . ' . . ... . . . 246 Syphilis, . . . . . . . . . . . . 247 Alcoholism, . . .--... . . . . . . . 247 Gynecic affections, . . . . . . , 248 Malaria, . . . ... . . . . . . . 249 Myositis, . . . ... . . , ... . 249 Osteomyelitis, . . ' ; . . . . . . . 250 Periosteitis, . . . . , .. . . ... 250 Muscular adhesions, . *. . . . ' . . . . 250 Skin Diseases, . . . . . . . . . .251 Plumbism, . . . . . 251 Typhoid fever, . . . . . ... . -.251 Pains of flat-foot - . . . 253 Obesity . . . . 254 CHAPTER XII. FIELDS OF FUTURE RESEARCH. Erysipelas ' 255 Tetanus, . 255 Lupus, ............ 256 Surgical Shock, .......... 256 Hodgkin's Disease, 256 Multiple Neuritis 257 Tabes Dorsalis, . . 257 Diabetes Mellitus, 257 Mental Aberrations, . 257 The Infectious Diseases, 257 Cerebro-Spinal Meningitis, ........ 258 LIST OF ILLUSTRATIONS. PAGE I. The Sprague Body Dry Hot Air Apparatus ... 3 II. Patient Undergoing Treatment in the Sprague Body Ap- paratus ......... 3 III. Patient Undergoing Treatment in Betz Body Apparatus 5 IV. Pedal End of a Modified Body Apparatus . . . 7 V. Cephalic End and Side of a Modified Body Apparatus . 9 VI. Lentz & Sons' Apparatus for the Local Application of Dry Hot Air 12 VII. The Sprague Apparatus for the Local Application of Dry Hot Air 13 VIII. Chair Devised by the Author for Use in Administering Local Dry Hot Air Treatments to the Shoulder Joint 17 IX. The Hopkins Generators for Applying Dry Hot Air via the External Auditory Canal . . .19, 20, 21 X. Applying Turkish-Toweling Strips Preparatory to Local Application of Dry Hot Air to Knee with Special Knee Apparatus ......... 45 XI. Patient Prepared for Local Application of Dry Hot Air to Knee with Special Knee Apparatus ... 47 XII. Patient Prepared for Local Application of Dry Hot Air to Leg from Knee Downward . . . . .49 XIII. Local Application of Dry Hot Air to Leg from Knee Downward with Betz General Local Apparatus . 51 XIV. Local Application of Dry Hot Air to Knee with Betz Special Knee Apparatus ...... 53 XV. Position of Covering Preparatory to Adjustment for Local Dry Hot Air Application to Shoulder . . 59 XVI. Shoulder Prepared for Local Dry Hot Air Application 61 XVII. Local Dry Hot Air Application to Shoulder ... 63 XVIII. Hip Prepared for Local Dry Hot Air Application . 65 XIX. Local Dry Hot Air Application to Hip . . . . 67 XX. Local Dry Hot Air Application to Lumbar and Sacral Regions 69 XXI. Patient Prepared for Local Dry Hot Air Application to Left Lung or Pleura? . .... 71 xx Illustrations. PAGE XXII. Patient Prepared for Body Dry Hot Air Treatment with the Betz Body Apparatus .77 XXIII. Local Application of Dry Hot Air to Left Lung or Pleurae 145 XXIV. Changes in Joint Structures Produced by Arthritis De- formans of the Fingers 179 XXV. Normal Finger Joints (a Fragment of a Needle Appears Imbedded in the Middle Finger opposite the Third Phalanx) . . .179 XXVI. Arthritis Deformans of the Knee . . . .181 XXVII. Patient Prepared for Local Application of Dry Hot Air to Abdomen .... .... 207 XXVIII. Local Application of Dry Hot Air to Abdomen . . 209 THERAPEUTICS OF DRY HOT AIR. CHAPTER I. APPARATUS. Outfit. Three forms of apparatus are essential in order that the most may be gotten out of dry hot air therapeusis as applied to the practice of general medicine: a large one for treating the whole body at once; a smaller one for treating hands, wrists, elbows, shoulders, backs, abdomens, hips, ankles, and feet ; and a short one, open at both ends, for treating anky- losed, flexed knees. Construction. All of these consist in general of metal cylinders lined with some non-conducting material, and are susceptible of being closed at both ends in such a way as to confine the air they contain about the part to be treated. The proximal end is closed by cloth attachments so constructed as to fit the different regions of the body to which it may be desired to apply the heat; the distal end by curtains of cloth or a permanent metal stopper. Gas, gasoline, electricity, and alcohol are used for generat- ing the heat, and high temperature thermometers are placed conveniently for registering the intensity obtained. There are several makes of apparatus on the market, the working principle of all being the same, but they differ in con- struction and price. That manufactured by F. S. Betz & Co., of Chicago, 111., and the Sprague apparatus made by the Kny- Scheerer Co., of New York, N. Y., are most commonly used in this country. As it is the cardinal principles of construction rather than the details that combine to render an apparatus 2 Therapeutics of Dry Hot Air. of this character therapeutically efficient, and as the details can be secured from the different manufacturers without difficulty, only the essential attributes that must be common to all dry hot- air machines in order that they shall be therapeutically re- liable will be mentioned here ; these are as follow : THE BODY APPARATUS. This should be capable of generating a heat of at least 300 F. in fifteen minutes and 350 F. in thirty minutes at the out- side, and of sustaining it there for at least an hour. The source of heat should be so arranged that the flame cannot be directed toward the patient without having some non-conducting material interposed, however great the distance between them. It should be provided with some arrangement, by valves or otherwise, whereby the air may be changed frequently with- out lessening the heat to any great extent. If free circulation of air in the apparatus is not attainable it will become so sat- urated with moisture that the skin of the patient will be in danger of blistering. Because of its size and weight this form of apparatus is not portable, hence is available only when the patient can be brought to it and in sanitariums or hospitals. When illuminating gas is used for heating this form of ap- paratus a pipe at least three-quarters of an inch in diameter, and connected directly with the large street service pipe, should be directly available for supplying the burners under the ordi- nary pressure conditions. With a smaller supply than this it will not usually be possible to secure the high temperatures without which satisfactory results cannot be attained in many conditions. Structural Modification of Body Apparatus. There are two forms of body apparatus; one in which both ends of the cylinder are closed by cloth curtains, and the other in which only the cephalic end is so constructed, the pedal end being permanently occluded by a metal stopper. As will be seen in a later chapter, the sensitiveness of the toes of some patients renders it necessary to conduct the application by this appa- Apparatus. I. The Sprague Body Dry Hot Air Apparatus. II. Patient Undergoing Treatment in Sprague Body Dry Hot Air Apparatus. Apparatus. n ratus with these members entirely outside of the heat reservoir; hence with the last-mentioned form of body apparatus it is desirable to effect some changes in its construction whereby this object may be attained, and the aid of a tinsmith must be invoked. The whole upper segment of the pedal end of the cylinder down to a point an inch or two below the under side of the rolling couch should be cut out, so that the end of the car upon which are the patient's feet can be rolled far enough through the pedal end of the cylinder to allow those members to project beyond the limits of the heat chamber. Curtains of heavy awning cloth should then be fitted to the upper and under borders of the opening thus made, in the same manner as they are arranged at the cephalic end of the cylinder, and of such shape and size as will allow the upper curtain to be tucked around the patient's ankles and the under curtain to be drawn snugly against the under side of the rolling couch. This arrangement answers the purpose admirably and is en- tirely effectual in preventing undue escape of the heated air. As the hot air reservoir in the machine with permanently- closed end is five feet long, it follows that with patients of medium height the head would be inside the reservoir when the feet were protruded as above, so that it becomes necessary also to cut off about sixteen inches of the cylinder ; this is most advantageously accomplished by taking some from each end. Cut IV shows the pedal end of such an apparatus which has been altered in accordance with the above suggestions, and Cut V shows the side and cephalic end. Six inches were cut off from the pedal end and ten inches from the upper half of the cephalic end, as shown in the cut. Another modification shown in Cut V is the hole in the side near the top ; it is seven inches square, fitted with a sliding door, and is used for ventilating the apparatus. The rapidity with which the air is changed may be regulated at will by sliding the door backward or forward so as to increase or diminish the size of the aperture. 12 Therapeutics of Dry Hot Air. THE GENERAL LOCAL APPARATUS. This is the one most useful to the general practitioner. A very important requirement is that it be portable as it is fre- quently desirable to employ it at the bedside in some acute diseases. It should be capable of generating a heat of at least 400 F. VI. Lentz & Sons' Apparatus for the Local Application of Dry Hot Air. in at most thirty minutes and of sustaining it there for at least an hour. The same conditions as to arrangement of the source of heat with relation to the patient apply here as with the body apparatus, but with more force, because the temperatures used are higher. An arrangement for securing free circulation of the air is also essential in this apparatus. A very serviceable modifica- tion consists in having the ventilation valve in the top enlarged to a hole five inches square and fitted with a sliding door; an Apparatus. \ 3 arrangement similar to that shown in Cut V on the body apparatus. , ; VII. The Sprague Apparatus for the Local Application of Dry Hot Air. THE KNEE APPARATUS Theoretically the same requirements noted in connection with the two preceding forms of apparatus should apply with equal force to this one ; there are practical difficulties in the way of securing the higher degrees of heat, however, which will be noted and discussed in the chapter on technique. Internal Distribution of Heat. An essential of prime importance as regards efficiency in all these forms of apparatus is that the heat should equalize itself 14 Therapeutics of Dry Hot Air. within narrow limits in all localities inside of the reservoir after the apparatus is thoroughly heated. Schreiber conducted a series of thermometric observations with some dry hot air machines of foreign make and ascertained that a difference sometimes obtained between the temperature of the air which actually came in contact with the patient, and that in the local- ity ordinarily occupied by the thermometer, of fifty per cent, of the thermometer reading. A construction producing such conditions renders the apparatus entirely unfit for therapeutical purposes. The discrepancy should not exceed five per cent, of the thermometer reading with a body apparatus, or fifteen per cent, with one designed for local application, and thermomet- ric determinations made by the writer demonstrate that these limits need never be exceeded. In apparatus of American manufacture they are not usually reached. The simpler the design of the machine the more effectually will the convection currents effect a thermal equilibrium. Elimination of Moisture. It has been suggested that dryness of the air in the cylinders might be maintained by the use of some absorbent substance inside the apparatus, or by passing a static electrical discharge through a tube located in the interior of the reservoir whereby the moisture would be precipitated upon the tube; by such means temporary slight irregularities of temperature caused by changing the air in the apparatus might be avoided. To dis- pose of the point it is only necessary to consider that at the high temperatures necessary for therapeutical purposes no chemical is known that would retain the moisture even if it were possible for it to absorb it under such conditions, and however successful we might be in precipitating the moisture by electrical or any other means, it would inevitably vaporize again immediately upon coming in contact with a solid body so heated. Changing the air, therefore, is the only practical means now available for maintaining dryness, and the efficiency and convenience of the procedure are such that no other need be sought for; its actual influence in disturbing the treatment temperature after the apparatus has once become thoroughly heated, is found in practice to be entirely negligible. Apparatus. 1 5 Fire-Proof Cloth Fittings. Although reasonably close observance of the cautions which will be detailed in the chapter on technique will eliminate any danger of serious ignition of the cloth attachments of the machines, yet scorching will occur which greatly shortens their periods of usefulness. This disadvantage may be obviated or lessened by substituting asbestos cloth for the fabric ordinarily used in their construction, or by treating the attachments be- fore they are used with some fire-proofing solution, the follow- ing being a fairly efficient example ; it is known as the " Home Office Method," and is used by the explosives department of the British Home Office for fire-proofing inflammable sub- stances : Sodium tungstate (normal salt) 4 ounces or q. s. to make Sol. Sat. Water, 30 ounces. Dissolve in the cold and add Sodium phosphate, 2 ounces, Water, 6 ounces, or a sufficiency of water to make the specific gravity of the solution 1140. The fabrics are soaked in this solution about half an hour until thoroughly saturated therewith, placed in the apparatus without being squeezed so as to retain in the meshes of the cloth all of the solution that can be held therein, and heated at 350 F. to remove the organic acid and cause the tungstate precipitate to be formed in the fiber, until dry. The use of asbestos cloth is the most satisfactory, as it elimi- nates absolutely any possibility of ignition; the fire-proofing solution lengthens considerably the life of the fittings, how- ever, and is less expensive. When asbestos cloth is used for the curtains of the body apparatus or the various attachments of the local machine, the wear upon it will be greatly lessened by having a layer of ordi- nary awning cloth outside of the asbestos, thus making a cur- tain of double thickness, the inner layer being of asbestos and the outer of awning cloth. In some body machines inflammable material, as wood, is 1 6 Therapeutics of Dry Hot Air. used in the construction of the couch upon which the patient lies. After a while this will burn out, when it may advan- tageously be replaced with heavy wire netting fastened to the couch at the ends and supported midway, where necessary, by thin iron bands running transversely with their ends fastened to the sides of the couch. This arrangement presents the advan- tage of forming a flexible surface which gives considerably to the prominent portions of the body, whereby the patient is ren- dered much more comfortable. Source of Heat. As already stated, gas, gasoline, electricity, and alcohol are used to excite dry hot air generators, and which agent is selected will depend upon the facilities of the individual oper- ator. If electricity is used the heating power of the current should be utilized through a non-luminous resistance and not through the medium of incandescent lamps. Gas is the most frequently available, is very convenient, en- tirely efficient, and exhibits but one disadvantage. In some cities the. pressure under which it is delivered, and in some houses the total supply capacity, are not great enough to fur- nish adequate heating power for the high temperatures fre- quently necessary of attainment, and if one applies many treatments outside of his own specially-equipped operating room, this point assumes an aspect of considerable importance. The difficulty may be overcome by always using gasoline (special gasoline burners and other fittings necessary when this agent is used will be furnished upon specification, by the manufacturer) when giving a treatment at the home of a patient, instead of depending upon the gas supply in the house. Strict adherence to this rule will save one many exasperating bedside disappointments. If the apparatus and treatment room are susceptible of proper ventilation, the possible deleterious influence upon the patient of aerial contamination by products of combustion devel- oped by the bare flames of gas-burners, sometimes urged against the use of gas for this purpose, will be entirely neg- ligible. Apparatus. Special Chair for Local Ap- plication to Shoulder. Although dry hot air may be applied to this region with the patient reclining upon an ordinary chair or couch, yet it will be found conducive to the comfort of both patient and operator and to the effi- ciency of the treatment if a chair especially adapted for this purpose is at hand. Cut VIII shows the front view of such a chair and also its lat- eral aspect. It is made upon VIII. Chair Devised by the Author for Use in Administering Local Dry Hot Air Treatments to the Shoulder Joint. the principle of a steamer chair, the frame being of wood and the support for the occupant of can- vas. When an ordinary chair or couch is used the cloth attach- ment connecting the apparatus to the shoulder will be crushed against the body when the patient 1 8 Therapeutics of Dry Hot Air. leans back' and the heated air will thus be prevented from reaching the posterior portion of the joint ; if the patient leans far enough' laterally to overcome this condition his position will shortly become irksome. The sharp backward curving of the side-pieces and .the shaping of the canvas back at the level of the shoulders shown in Cut VIII obviate this difficulty entirely and render it possible to carry the heat as far toward the median line as the inner border of the scapula. Location of Apparatus. Little need be said as to the setting of the local dry hot air generators except that the comfort of both patient and operator will be enhanced if the room wherein the treatment is to be given is provided with a window which can be opened during the application. The great majority of these treatments can be given at an ordinary bedside as conveniently as in a room especially prepared for the purpose. The greater size, hence greater heating and de-oxygenat- ing capacity as regards the air of the room, of the body appa- ratus, however, renders free ventilation by open windows or otherwise an essential feature of the apartment wherein these applications are to be administered, and in the summer time at least an electric fan, so arranged that the breeze can be directed upon the patient, will be found to constitute a most desirable feature of its equipment. It is also desirable to have the bathing facilities as near the treatment room as possible so that the patient will not have far to go after cooling. A couch upon which the patient can be given an alcohol rub and left to rest for an hour or two after the treatment, should be located in a room conveniently accessible from the bathroom. Other minor details will suggest themselves as the individual operator develops his facilities. DEVICES FOR APPLYING DRY HOT AIR TO THE OPEN CAVITIES OF THE BODY. Modifications of the previously described forms of apparatus, more or less well adapted for applying this agent to open cavi- ties, are procurable, but as they have been employed to only a limited extent as yet, their actual therapeutical value cannot be passed upon with any degree of conclusiveness. Apparatus. External Auditory Canal. One of them, however, the Hopkins heater, designed by Hopkins, of Cleveland, O., for use in the external ear and made by the Terry Heater Co., of Cincinnati, O., deserves more than a mention, because of the very satisfactory results that have been reported from its use. It is made in three forms so that alcohol, illuminating gas, or electricity may be utilized as the source of heat. The air is compressed before being heated, so that it is delivered to the field of operation with some force. The Alcohol Heater (Cut IX). This form consists of a metal cone segment, around the inside of which is wound a IX ./. Alcohol Heater. IX A. Cross-Section. tapering coil of copper tubing. Beneath it is an alcohol lamp which heats the coil to a high temperature in a few minutes. 20 Therapeutics of Dry Hot A ir. Compressed air from a tank, pump, or bulb enters the heating coil at the bottom through rubber tubing, and leaves it at the top through a metallic delivery tube having two rotary joints which make it adaptable to any position of the patient, the delivery tube terminating in a vulcanized fiber ear-tip shaped somewhat like an ear speculum. This ear- tip is said not to become inconveniently hot even when the hottest air is passing through it. The capacity of this heater as regards temperature elevation of the air delivered is said to be much less than that exhibited by those utilizing gas or electricity. The Gas Heater (Cut IX). This form consists of a blue- x ' flame burner, over which is similarly arranged a larger coil o*f IX B. Gas Heater. IX B. Cross-Section. copper tubing, and the compressed air enters and leaves the coil in the same manner. Apparatus. 21 The Electric Heater (Cut IX). This machine is operated by the I lo-volt lighting circuit through an ordinary socket and plug and can be used on either the direct or alternating current. IX C. Electric Heater. IX C Cross-Section. It consists of an air-tight tube holding within it a coil of wire which is heated by the current. This tube is surrounded by a nickel-plated envelope, the intervening space being packed with asbestos. The wires enter the tube at the bottom through a bushing. The compressed air enters the tube at the bottom and leaves it at the top as with the alcohol and gas heaters. Air passing through this appliance acquires its maximum tem- perature elevation (over 400 F.) in eight minutes. A marked advantage exhibited by the Hopkins machines is that the compressed, heated air is compelled to escape, with 22 Therapeutics of Dry Hot Air. a degree of force which is absolutely controllable, at exactly the spot desired and nowhere else. Directions for setting up and operating all of these outfits, together with complete fittings and descriptions thereof, arc furnished by the manufacturers. CHAPTER II. PHYSIOLOGICAL ACTION. COMPREHENSION of the applicability of this agent to different disease processes, of the rationale of its action, and of the value of the services it renders will be facilitated if the following is borne prominently in mind while considering this subject, viz., that in at least a large majority of pathological conditions Nature's attempt to rid herself of disability is sim- ply and solely through an accentuation or exaggeration, direct or indirect, of the normal metabolic processes. As illustra- tions may be mentioned the increase in local trophic activity accompanying repair in wounds ; the increase in cell production whereby it is attempted to wall off a chronic inflammatory focus from the rest of the organism ; the acceleration of metabolism whereof the phenomenon of fever is the outward and visible sign, is also believed by many to be simply an expression of Nature's effort to rid herself of deleterious agencies by augmen- tation of the normal vital processes, through which alone is she able to resist or destroy such agencies. The greater the facility and vigor with which normal tissue changes are carried on the greater will be the individMal's vitality, hence capacity for resisting influences antagonistic to his well-being and of overcoming the results of such in- fluences if he should become a victim thereto. Differentiation from Other Methods of Administering Heat. Electric Arc and Incandescent Light Baths. A most important point to be borne in mind in this connection is thai dry hot air is not radiant heat or moist heat. The physiological influences of the electric arc and incandescent light baths are radically different in several respects from those of the dry hot air application proper, the former being a combination, in 23 24 Therapeutics of Dry Hot Air. varying proportions and degrees of intensity, of both heat and light effects, the radiant element being always predominant, however. With the dry hot air application, properly so called, we do not get any of the characteristic effects of light waves upon cell life, and clinically, the work of Cleaves, Crothers, and others would seem to indicate that the radiant heat bath differs radically in at least one particular from its non-luminous congener, viz., in its greater power of producing sedation of the irritable nervous system. The purely thermal element in the radiant heat application is necessarily much less intense than in the dry hot air appli- cation proper because of the predominance of the chemical rays in the former. We should expect, then, that radiant heat would not be able to perform the work of dry hot air, and that the latter would fail in some respects to accomplish the results attainable with its radiant relative, and experience proves this to be true. The explanation of the difference in the physio- logical influences characteristic of dry hot air as compared with radiant heat, is found principally in the greater power exhib- ited by dry hot air to induce elimination and to influence by reflex stimulation the deep nerve centers. Hydrotherapy. Its physiological effects must also be dif- ferentiated from those of the various hydrotherapeutic proced- ures in which a greater or less degree of heat is employed. In the latter the degrees of heat administered are necessarily much less than with dry hot air applications proper because they are applied by means of water, and the physiological effects of mild degrees of heat are in some respects directly the reverse of those obtainable by the use of high intensities. In addition to this we have to reckon, in some of the hydriatic modalities, with the element of percussion, which still further modifies any possible resemblance that might otherwise obtain. The differences in the elements which combine to produce the characteristic influences obtainable by the use of these three methods of applying heat, then, are sufficiently marked to con- stitute radical differences in the spheres of action of dry heat, radiant heat, and hydrotherapy, and in the securing of a satis- factory therapeutical result the selection becomes a matter of Physiological Action. 25 importance; they are by no means mutually interchange- able. Varieties of Application and Nomenclature. There are two varieties of dry hot air applications ; one where the greater part of the body surface, sometimes the whole of it up to the neck, is subjected to influence and which is denominated the " General Application " or " Body Treatment," and the other where only the part involved in a pathological process is in- cluded in the field of operation and which is denominated the " Local Application " or " Local Treatment." The physio- logical actions of these two varieties of administration differ from each other in degree and to a certain extent also in kind ; we will, therefore, consider them separately, beginning with the major procedure. GENERAL APPLICATION. Clinical and laboratory observations made in connection with patients under treatment by the writer have demonstrated that the following objective phenomena are susceptible of imme- diate induction by the body treatment, and that they persist with decreasing intensity for from four to forty-eight hours, rarely longer, the lime varying in different diseases and with different patients. Body Temperature. The mouth temperature rises from one to five degrees Fahrenheit, according to the length and intensity of the application and the susceptibility to stimula- tion of the individual patient's nerve centers. Pulse. The rate is accelerated from thirty to fifty beats per minute, and the impulse is markedly increased in volume. If it was weak before treatment it becomes strong during administration. If the application is continued too long it loses its volume and strength, becoming rapid, small, and soft; under these conditions the patient becomes faint, dizzy, and nauseated. Respiration. The breathing deepens some and the rate increases from five to ten cycles per minute; this modification of function is not accompanied by any sensation of oppression on the part of the patient, however ; rather the reverse, in fact. 26 Therapeutics of Dry Hot Air. Skin. The capillary areas become injected, but this phe- nomenon is not as marked in the regions actually in contact with the heat as in the local treatment. The fact that the capillaries of the face, which is never subjected to the heat, share this general distention even when constantly under the influence of the breeze from an electric fan, demonstrates the profundity of the influence obtained and that it is essentially reflex in character. The sweat-glands functionate copiously, sometimes excreting several pounds (from one to five) during treatment; if dropsy is present the excretion may be much greater even. Blood. The number of white corpuscles is increased in different cases from fifteen to fifty per cent. The red blood cells are increased from ten to twenty per cent. Urine. The quantity passed in the twenty-four hours succeeding the treatment is usually increased from twenty-five to one hundred per cent, over that passed during the twenty- four hours preceding. In occasional instances, however, a de- crease in the quantity is observed. The quantity of urea excreted in the twenty-four hours suc- ceeding the treatment is increased from fifteen to sixty per cent, over that excreted during the twenty-four hours previous. Variations in Extent of Influence Induced. The degrees in which these several phenomena are found to be present differ widely in different cases, and at present it is not possible to define positively the reasons for the variation or the conditions under which it may be expected to appear. A general rule which seems to apply fairly constantly, however, is that the greater the departure from normal function in a direction the reverse of that in which tends the influence of the dry hot air treatment, the more pronounced will be the effect of the treat- ment in the direction indicated above. For instance, in patho- logical conditions characterized by a deficient excretion of urine or urea, the increase in the excretion of these compounds may be expected to be pronounced; in cases exhibiting a marked hyperleucocytosis on the other hand, only a slight increase in the number of leucocytes, sometimes none at all, and again Physiological Action. 27 an actual decrease may be observed, especially if the patho- logical process which is responsible for the excessive formation of white corpuscles is gotten under immediate control. In healthy individuals who exhibit no departure from the normal, only slight modification may be expected in most cases ; nearly always some is observable, however, in the directions noted above. Subjective Phenomena. The sensation is rarely disagree- able to the patient, but quite the reverse usually. A pleasant languor is produced after about ten minutes which lasts for an hour or two; after the treatment the patient usually becomes drowsy and sleeps. If the application is continued too long the languor gives place to exhaustion, sometimes accompanied by cardiac palpitation and oppressed breathing which may per- sist for hours. A sense of exhilaration and increased vitality follows the treatment when well administered. Rationale of Action. Through the elevation of the tem- perature of the body en masse and the profound reflex stimu- lation of the deep nerve centers, are secured, first, a more rapid and complete oxidation of effete materials which are clogging metabolic processes, figuratively speaking, into normal ex- cretory products urea for the kidneys, CO 2 for the lungs, etc. which are then easily disposed of by the appropriate organs; and, second, an accelerated production of healthier and more vigorous cell elements, which are much better able than their predecessors to resist toxaemia and microbic inva- sion and to carry on the function of tissue reconstruction. We not only obtain a corrective influence in nutritional and con- stitutional disorders, the origin of which is in the trophic nervous system, but if the patient is suffering from an infec- tious invasion we increase vastly the resisting power of his phagocytes and tissue elements. The profuse perspiration carries out with it a certain amount of any toxin that may be present and thus assists in relieving depression of vital nerve centers. The functional activity of every organ and tissue in the body- is immediately augmented, but this exaltation of function is not followed by a reactionary debility if good judgment and 28 Therapeutics of Dry Hot Air. proper technique have controlled the administration. Patients usually continue to improve in health and strength for months after a course of body dry hot air treatments. The physiological action of this measure, then, is predomi- nantly reflex through the sympathetic and spinal nerve centers, the area of skin treated being so great that the capillary cir- culation is able to dissipate the heat before it penetrates deeply enough to exert its action directly upon the underlying struc- tures to any great extent, herein differing, as we shall see, from the local application. Sphere of Action. When we consider the large number of pathological conditions which are dependent wholly or in part upon the occurrence in the system of sub-oxidation, and the retention in the circulation and tissues of its products or of various toxins of other origin, the influence of the body dry hot air application upon oxidation and the excretory function assumes an interesting significance ; and when, in addition, we think of the number and variety of diseases in which the resistive and reconstructive functions are deficient, the reflex nervous phenomena and modifications in the composition of the blood noted above are scarcely less attractive. The field of usefulness of this measure, therefore, extends within limits of considerable magnitude. LOCAL APPLICATION. Elements of Physiological Action. This therapeutical measure affects physiological function in two ways : first, by a direct stimulation of cell metabolism in the part treated, due to the raising of its temperature en masse; and, second, by reflex acceleration of cell nutrition set up by the stimu- lating influence of the heat upon the numerous nerve endings in the skin. Temperature Elevation of Part Treated. It is, of course, not possible to raise the temperature, en masse, of one portion of the body very much higher than that of the rest of the organism, but by placing the bulb of a clinical thermometer at the bottom of a deep sinus and then applying a local dry hot air treatment it has been demonstrated that an increase Physiological Action. 29 of about twelve degrees Fahrenheit can be induced. This is enough to accelerate oxidation processes very perceptibly. In diseases characterized by the presence of pathogenic micro-organisms in the part treated, as local septic infection or pneumonia, the inhibitive influence of this element of the physiological action upon the growth and activity of the germs is very evident. It has been suggested that the germs in these cases were directly destroyed by the heat, but this view is improbable ; there is no experimental or clinical evidence avail- able which can be looked upon as indicating that it is possible to raise the temperature of any portion of the body sufficiently high to render such a result attainable. It is more likely that the effects are produced indirectly through augmentation of cell vitality and acceleration of local metabolism. Reflex Effects. Through the reflex influence is obtained an emphatic local hyperaemia which, together with the stimu- lation of the trophic nerve supply of the part treated, results in greatly increased local nutrition. Copious perspiration appears upon the region treated and in greater or less degree upon the rest of the body. This secre- tion is strongly impregnated with fatty acids, whatever the disease from which the patient is suffering, or even if he has no disease at all. If a toxin is being elaborated in the part treated a large proportion of it is thus eliminated before it enters the general blood current, and that which has already entered the circulation is eliminated in direct proportion as the perspiration induced upon the body surface is profuse. To these profound influences upon the circulatory, excretory, and metabolic functions of the part whereby stasis is relieved, is probably due the powerful effect of dry hot air treatments in relieving pain and swelling. That these applications are sometimes capable of exerting profound reflex influence upon parts physiologically related to but actually distant from the field of direct administration, was demonstrated in a case reported by Walsh. The patient had eczema of both hands; one only was subjected to the treatment, yet both got well. Cases also have been reported where pains in a limb on one side of the body have been 3O Therapeutics of Dry Hot Air. relieved while the corresponding limb on the opposite side was being treated. It will be observed that all of these effects tend greatly to increase the assimilation and absorption of remedies, in the tissues wherein such effects are induced. General Body Temperature and Pulse. These are rarely much modified by the local application. Patients will some- times exhibit an increase of a fraction of a degree in the former or an acceleration amounting to eight or ten beats per minute in the. latter ; modification to these extents is, of course, not capable of influencing the general metabolic functions markedly. Sphere of Action. The influence of the local application, then, is practically confined to the part treated. What effects are produced upon the organism as a whole are principally sec- ondary to changes induced in the local disease focus; hence it will not and should not be expected to cure, unaided, pathology of general or central primary causation. For in- stance, local treatments alone will not cure the joint lesions of arthritis deformans because these lesions are but secondary manifestations of impaired general trophic functions; they will in some instances relieve the pain temporarily, however. In early localized septic infection, on the other hand, the pri- mary pathological focus is in the part affected, and local dry hot air treatments will usually produce a rapid and radical cure; the organism at large will be secondarily benefited during the curative process, by the lessening of pain depression and of the quantity and virulence of the toxins elaborated in the original pathological focus, in direct proportion as the local lesion improves. Summary of Physiological Influences. General Application. First, an immediate and powerful stimulation of the vital physical functions which is evidenced, before the patient leaves the apparatus usually, by augmented vigor of the heart action and pulse and a lessening of nervous erythism when such is present as a result of acute disease processes. Physiological A ct ion . 3 1 Second, a reflex stimulation of the functions of all the organs and tissues of the body which results in, a, a degree of elimina- tion of urea and other katabolic excreta probably unequaled by that producible with any other measure now known ; and, b, an amount of general reconstructive activity which would also seem to be in excess of that derivable from the use of other agents. Local Application. First, immediate relief of circulatory stasis. Second, increased blood supply to the part treated. Third, acceleration of the nutritive processes of the part due to reflex stimulation of the trophic nerve supply. Fourth, an increase in the temperature of the part treated whereby the chemical reactions constituting local metabolism are facilitated. (It is probably through intensification of local physiological resistance, brought about by the four above- mentioned effects, that the inhibitive influence upon the de- velopment of pathogenic micro-organisms that may be present, is secured.) Fifth, the withdrawal of a large amount of fluid from the part treated by reason of the profuse perspiration induced. Clinical Applicability. From the above it will be seen that the pathological condi- tions in the treatment of which dry hot air is useful, can be divided roughly into three groups. Although this division is entirely arbitrary, yet it will serve to furnish a bird's-eye view of the field of action, and may quicken comprehension of its applicability to different cases. First, those disease conditions in which the essential primary pathology is strictly local and for the cure of which the local dry hot air application is sufficient; as illustrations may be mentioned sprains, local septic infection in its early stages, and many cases of rheumatism. Second, cases wherein the essential primary pathology is local but resultant conditions in the organism at large have compli- cated the original symptom complex, and for the relief of which the additional influences of the body treatment upon the 32 Therapeutics of Dry Hot A ir. general bodily functions must be invoked ; local septic infection with profound systemic toxaemia is a good illustration of this class. Third, the constitutional, diathetic, and general diseases, in which only the profoundly-acting influences of the body treat- ment upon general metabolism are of benefit. As illustrations may be mentioned Bright's disease of the kidneys, chronic true gout, and arthritis deformans. Analogies. It will be observed that the physiological action of dry hot air is made up of most of the integral elements which also combine to form the physiological actions of the various hydro- therapeutic procedures, electricity, mechanical vibratory stimu- lation, massage, etc., but that such elements as are common vary in the proportion of intensity with which they manifest themselves in the characteristic influences of these different remedial measures; hence in some directions dry hot air is more efficient than any of them. It is frequently advantageous, however, and as will be seen later sometimes necessary, to com- bine other elements of therapeusis, physiological, medicinal, and surgical, with dry hot air in order to accomplish certain results. None of them alone will do the work of several com- bined in many cases. The mode of action of thermotherapeutical influences is also directly parallel with and immediately in the line of the normal physiological forces concerned in cell development and tissue reconstruction, hence the only pernicious after-effect to be guarded against is reaction from over-stimulation, the avoidance of which will be discussed in the succeeding chapter. Fallacies. As to Identity of the Influences Exerted by Hot and Cold Applications. A belief is more or less current that the effects upon physiological function of degrees of heat and cold which depart from the normal body temperature to the same extent in their respective directions, are identical. This belief is based upon a conception of the physiological actions of such applica- Physiological Action. 33 tions, which assumes that irritation of nerve endings in the skin constitutes the only factor involved. If such were the case the above-mentioned belief would undoubtedly be true, but reflection shows the problem to be much more complicated. The gross physiological effects of either hot or cold applications are made up of at least three component influences; first, that obtaining through modifica- tions of sensation (including psychic impressions) ; second, that obtaining through the reflexes ; and third, that dependent upon the direct, inherent, physical and chemical results of heat- ing or chilling body tissues. The gross physiological influence being a composite phenomenon therefore, the operation of factors that alter the nature of any of the elemental constituent influences, or change the proportionate prominence with which they enter into the combination, would necessarily modify the physiological result. To convince oneself that a radical difference obtains as regards sensation, it is only necessary to immerse the hand or foot in water at 73 F., and after the member has fully recov- ered immerse it in water at 123 F. (nearly the extreme limit of temperature elevation at which contact with water can be tolerated), which is as much hotter than the normal as the former is colder; if the immersion is not maintained long enough to obtund sensibility the deduction will offer no diffi- culties. Another discrepancy, suggested by the preceding paragraph, is that contact with water can be tolerated at a much greater departure from the normal body temperature, in the direction of cold than of heat ; more than twice as great with the majority of individuals. This discrepancy involves not only sensa- tion, but the actual physical, structural integrity of the tissues subjected to influence. To demonstrate a substantial difference in reflex effects, immerse the feet of a person who is perspiring freely in water at 73 F. for a few seconds and note what a lessening in the emunctory process takes place; conversely, immerse the feet of a person who is not perspiring, in water at 123 F. and see the perspiration start. 34 Therapeutics of Dry Hot A ir. A disparity in the direct, inherent, physical effects produced by actually chilling or heating body tissues, becomes at once apparent to anyone who has observed the different manner in which an incarcerated hernia responds to the two applications. Such a disparity is also well illustrated by the fact that super- ficial neuralgias and other painful conditions are sometimes relieved by hot compresses and aggravated by cold, and vice versa. Nothing conclusive can be said as to the prominence of the first-mentioned factor as a modifying element ; it has not yet been determined in just what degree or manner differences in sensation are active in influencing physiological function. We do know, however, that a remedial measure that is not un- pleasant to the patient is likely to produce better results than one which is unpleasant, and the application of which is there- fore anticipated by him with dread. The therapeutical appli- cation of dry hot air is very rarely unpleasant in the slightest degree, that of cold is not infrequently fraught with torture both mental and physical; patients usually look forward with pleasure to the former, and frequently with terror to the latter. As regards the reflex tendencies of cold and heat, it is reasonable to infer from oft-observed clinical and experi- mental findings, that they are exerted in the same directions as are the direct and inherent effects ; i. e., an application of cold would tend primarily to affect the metabolism and nervous phenomena of the area influenced as would cold if applied directly and long enough to chill the parts ; an application of heat would tend primarily to affect the area influenced as would an actual raising of its temperature en masse. The proposition stated in the foregoing paragraph assumes that neither the heat or the cold is applied with sufficient intensity to excite protest from the tissues under influence. The precipitation of protest would introduce the element of irritation into the equation, and the effects of pure and simple irritation are probably identical, whether provoked by either heat or cold. The direct, inherent, physical effects of cold and heat may be indicated as follows : Physiological Action. 35 First, chilling a body tends to check chemical changes going on among its component atoms ; as applied to the human body the direct inherent effect would be to hinder metabolism, which involves cell and tissue reconstruction as well as destruction or waste. Second, heating a body, on the contrary, tends to facilitate chemical changes going on among its component atoms ; as applied to the human body the direct and inherent tendency would be to accelerate metabolism, which, again, involves cell and tissue reconstruction as well as destruction or waste. Applying these principles practically, then, we find that the application of cold to the body brings into play a force which is antagonistic to normal metabolism and catabolism, nervous and glandular function, as represented by chemical change and the facility with which nerve impulses are transmitted. If the application is sufficiently intense, the organism will resist at the first impact ; if contact is prolonged sufficiently to overcome this initial resistance, metabolic processes will be retarded in direct proportion as the tissues are chilled. After the inhib- itory effect has passed away, the organism will endeavor to overcome or make up for the effects of temporary suspension of vital processes by temporarily increasing normal processes and functions ; by manifesting reaction. The stimulant influence of cold then, is constituted solely and entirely by this tendency toward resistance and reaction, hence the degree of stimulation obtainable with it is limited absolutely by the vitality, or power to resist such antagonistic influences, of the organism under treatment. If the organism is so weakened by disease or any other factor as to be unable to resist with a requisite degree of vigor, depression instead of stimulation will result. The application of heat to the body, on the other hand, brings into play a force and induces conditions which are entirely in harmony with the normal processes, hence there will be no initial resistance and no temporary paralysis of metabolism which must be overcome before stimulation (reaction) sets in. Its influence, being inherently in harmony with normal metabo- lism, is accelerant to these processes, in some degree, from the 36 Therapeutics of Dry Hot A ir. start and continues so to be throughout every phase of action contingent upon its sustained application. ,When we recall that in the great majority of pathological conditions the human organism endeavors to rid itself of dis- ability solely and entirely through accentuation of the normal metabolic processes, the deduction as to the relative applica- bilities of cold and heat to such pathological conditions becomes immediately apparent. Another important fact exhibiting a prominent therapeutical bearing and contingent upon the foregoing, is that cold is directly, inherently, and reflexly inhibitive to elimination as well as cell production and increases the former function only secondarily through the reaction obtainable, and that heat, on the contrary, is directly, inherently, and reflexly accelerant to elimination, primarily and throughout the whole period during which it may be applied. The element most active in producing the immediate, visible stimulation of the vital signs obtainable with dry hot air, how- ever, to apply the foregoing directly to our immediate subject, is irritation of the nerve-endings in the skin when the heat has become intense enough to excite protest (reaction) from the deep nerve centers. This protest, however, is not against an inherently antagonistic force which threatens inhibition and it has not been necessary to paralyze normal processes in order to elicit the reaction, hence it would be expected to act more kindly than cold. Further, this irritation of nerve-endings occurs late in the application and after the organism has been so influenced through acceleration of its vital processes as to be capable of more efficient reaction, as suggested in the pre- ceding paragraphs; the gross stimulation obtainable with this agent therefore is much more profound than when cold is employed. The inference, then, that the gross effects of cold and hot applications are identical is not demonstrable by experiment, confirmable by clinical experience, or defensible by any line of logic based upon observed physical or physiological facts. We are justified therefore in making the claim, suggested by prac- tical experience, that radical differences exist and that they Phys io logical Action. 37 demonstrate that dry hot air has a place in the treatment of disease that no other known measure can fill ; that to secure the best therapeutical results these differences must be recognized, distinguished, and thoughtfully considered in connection with the management of different disease processes. As to Identity of the Effects Producible with Dry Hot Air and Hydrotherapy. The hydriatic modalities depend for the induction of their various influences upon the bringing into contact with the skin of different degrees of heat and cold through the medium of water variously manipulated. As far as the inherent effects of heat and cold are involved in hydro- therapeutic applications all that has been said in the preceding section applies equally well here, but, as has previously been stated, hydriatic and dry hot air applications are not directly comparable because practical difficulties render it impossible to apply the same degrees of treatment intensity; the conditions surrounding the us_e of these two remedial measures therefore are not susceptible of identification for purposes of compar- ison. Further, some hydriatic procedures include percussion, an element which has no parallel in any method of dry hot air therapy. The practical difficulty which obtains in those hydrotherapeu- tical procedures involving heat consists of the fact that nothing like the same degree of treatment intensity can be applied to the skin through the medium of water as through the medium of air, because the structural integrity of this tissue is seri- ously endangered when the temperature of a wet application approaches 170 F. and the result of contact at 212 F. needs only to be mentioned to be appreciated. Air can safely be applied to the skin at 400 F. and sometimes more if proper precautions are observed, and its characteristic and most desir- able effects are not produced at a temperature lower than 300 F. The nearest approach to a parallel which dry hot air therapy can offer to percussive hydrotherapy is when a dry hot air treatment is followed by mechanical vibratory stimulation, and when the organism has had its metabolic and reflex activities intensified to such a degree as obtains after a dry hot air appli- 38 Therapeutics of Dry Hot Air. cation it would seem as though this combination would dis- count the hydriatic modality as regards intensity of both local and general influence ; this, however, is a matter for future observation to decide. As regards comparison of the effects of general cool and cold hydriatic applications and dry hot air, to the whole or the greater part of the body surface, no one who has ever con- trasted the appearance of a typhoid patient, shivering, cyanosed, and with weakened pulse after a bath only fifteen or twenty degrees Fahrenheit below the body temperature, with that of such a patient who has been given a body dry hot air treatment, will any longer entertain doubt as to the existence of a radical difference in the gross effect of the two measures. The gen- eral dry hot air application never produces shivering or cya- nosis with all that they imply, no matter whether it is adminis- tered at ten or three hundred degrees above the normal body temperature; on the contrary, the sedative influence upon the nervous system is invariably marked, the patient usually falling into a quiet sleep within two hours, and the ruddy glow of the skin, warmth of the extremities, and augmented volume and force of the pulse which ensue demonstrate that a direct and powerful sedative and tonic force has been at work. The elucidation of the variation in these two pictures is found in the fact that the patient who is cyanosed and responding badly to the cold bath has not sufficient vitality to react ade- quately, while the influence and effect of the general dry hot air treatment are such that much less reactive power on the part of the patient is necessary for the production of its full effect ; the thermal agent furnishes inherently and directly the greater part of the effect demanded. No matter how carefully and conscientiously the hydrothera- peutic treatment of typhoid fever is carried out the above- described picture not infrequently obtains, and we have seen profound and alarming prostration follow twenty minutes of simple cold toweling of a patient in bed and which refused to yield to strychnia hypodermically, whisky, and vigorous rub- bing, overcome at once by fifteen minutes of general dry hot air at 300 F. ; a very good practical indication that the measures Physiological Action. 39 exert radically different influences. In addition to this, typhoid patients sometimes complain bitterly of the hydriatic applica- tion, but I have never heard one object at all strenuously to the general dry hot air treatment ; on the contrary, they usually like and feel comforted by it. After what has been said in this and the preceding sections, a statement, which has been published, to the effect that dry hot air applications are " not complete except when systematically employed in conjunction with hydrotherapy," will need but brief discussion. The profundity and intensity characterizing the acceleration of functional and general metabolic processes, evoked by a thoroughly-aclministred dry hot air treatment, is limited only by the inherent capacity of the organism under influence for carry- ing on these processes; hence they could not be further increased by the application of any other force acting from without the organism, and certainly not by a force which depended for its stimulating properties upon the reactive capacity of such organism. If the dry hot air were not intelli- gently and thoroughly administered (as when the degree of heat employed is not sufficiently intense, etc.) and if the pa- tient's reactive powers were adequate it would be obvious that the application of an additional stimulant would be beneficial ; when shortcomings in technique are eliminated, however, dry hot air rarely, if ever, needs to be followed by hydrotherapy in order that its beneficent work may be complete. This does not mean, however, that hydrotherapy is not of value, and of great value, when combined (alternated) with dry hot air applications; on the contrary, in some conditions such employment of hydriatic measures is of the greatest assistance. As to the Rationale of Its Physiological Influences.- One of the most prevalent errors in the popular conception of the modus operandi of the curative powers of dry hot air, is that it produces its effects merely through the induction of in- tegumental hypersemia and toxin elimination as represented by profuse perspiration ; this has led to applying the agent at tem- peratures only sufficiently high to produce sweating, that is, from 200 to 250 F. By this means elimination has been se- 4O Therapeutics of Dry Hot A ir. cured, and very effective elimination, too, as far as the perspira- tory function was concerned, but that was all. Now to obtain the most profound and permanent curative influences of dry hot air, we must not only induce elimination but supplement and perpetuate as far as possible the advantage dependent thereon, by augmenting the trophic reconstructive functions whereby we increase the patient's constitutional resistance ; and effective stimulation of these processes is not possible unless the higher temperatures, from 300 to 40x5 F., are used. As to Permanence of Results. One commonly hears it stated that the curative results obtainable by the use of dry hot air are not permanent. This criticism is largely based upon the belief that dry hot air is only a palliative measure, like a dose of morphine in painful conditions, for instance, and would never be entertained if the profound influences upon physiological function which we have been discuss- ing were given due .consideration. The belief was origi- nally given weight by the observation that cases of rheumatism treated with dry hot air alone very frequently " came back/' but this merely meant that the disease was not cured because the thermal agent was not properly supported by the simul- taneous administration of appropriate drugs in appropriate dosage. The therapeutical characteristics exhibited by dry hot air consist in its power to accomplish, either alone or in com- bination with other indicated agents, that which it is impossible for any other combination of agents to accomplish without its aid. Another fact bearing upon this criticism is that when we have carried a patient through an attack of pneumonia, typhoid, rheumatism, or any other disease, except where the aetiological factor has been removed surgically, we cannot assure him that he will never have the disease again, no matter what curative agents we have employed. We can only be certain that this one attack has been extinguished. If appropriate environmental and constitutional conditions again obtain he will surely have to sustain another attack, no matter how perfect may have been his health in the meantime. When men no longer contend with conditions which engender habits of life that are inconsistent Physiological Action. 41 with their perfect physical health, then, and not till then, shall we be immune from repeated attacks of disease, and when that millennium has arrived, dry hot air and most of our other reme- dial agents will have retired to the oblivion of complete desue- tude. In closing the consideration of this division of our subject 1 desire to emphasize the fact that the key to the attainment of satisfactory results by the use of dry hot air as a thera- peutic agent is the same as with any other remedial measure, medicinal or otherwise, viz., a thorough knowledge of the phys- iological action of the agent, and a logical consideration of the same with reference to the pathology of the individual departure from the normal for which a remedy is being sought. CHAPTER III. TECHNIQUE. THE difference between proper, thorough technique, and the reverse, frequently constitutes the difference between success and failure in clinical results; hence this subject is a very important one and merits close study. The current idea that it is a perfectly easy matter for any physician to secure a dry hot air apparatus and successfully treat his patient, without any special knowledge of the agent or the management of it with reference to different pathological conditions, is entirely erroneous and much to be deplored. When this unfortunate impression has been eliminated better results may be looked for from its general employment, and appreciation of its beneficent powers will succeed the lack of confidence with which it is so frequently regarded at present. Inefficient technique, and lack of adequate familiarity with its physiological action and clinical possibilities, whereby it has been called upon to produce results which a reasonable degree of enlightenment upon these points would have taught should never have been expected of it, have brought upon dry hot air a vast deal of undeserved opprobrium. Methods of Preparation. There are two ways of giving treatments; with coverings and without. The latter method is based upon the assumption that the perspiration will be evaporated off from the skin by the high degree of heat as soon as it is formed; while this should per- haps be so theoretically, yet experience demonstrates that it does not always take place. A large proportion of the perspi- ration does evaporate immediately, and if a low degree of heat (200 to 250 F.) is used, the administration without coverings is very satisfactory. But it is ordinarily necessary to employ greater intensities (350 to 450 F.) and then the sweat-glands 42 Technique. 43 functionate so copiously that the secretion is not all vapor- ized immediately and the residue becomes hot enough to blister. Employment of the covering obviates this danger; as it invests the skin closely the perspiration is absorbed by it as fast as it collects and the attenuation of the secretion effected by distributing it through the meshes of the fabric facilitates its conversion into steam by the heat, when it readily diffuses off into the air surrounding the part under treatment. The material for the covering should be loose-meshed and as absorbent as possible, and the cheap grades of Turkish toweling have given me greater satisfaction than anything else. It has been urged as an objection against the use of wrappings, that the heat would be dissipated by its passage through them to such an extent that although the treatment could be applied at a much higher temperature than when they were not used, yet the layers of air in immediate contact with the skin would not exhibit a temperature in excess of that which it would be possible to apply if the application were made to the bare skin. To dispose of the point it is only necessary to insert a high-temperature thermometer between the layers of the wrapping during a treatment, remove it quickly, and note the reading. Again, anyone who has observed the methods when given side by side cannot fail to be impressed by the variation obtaining, both as regards therapeutical influence and the comfort of the patient. LOCAL APPLICATION. Preparation. It is well to have the patient remove all of his clothing and don a flannelette robe or suit of pajamas in which to undergo this treatment; he is thereby enabled to go home in dry gar- ments instead of those dampened by perspiration. Arms and Legs. For treating these members and portions thereof the Turkish toweling should be cut into strips about seven inches wide and five feet long, hemmed and rolled like a surgical bandage. It is applied the same as a roller bandage 44 Therapeutics of Dry Hot Air. (Cut X), not tightly, but closely enough to obtain even and intimate contact between it and the skin. There should then be wound about it, paying especial atten- tion to the creases and recesses, a line of tape with the turns about one inch apart (Cuts XI and XII) ; this will press the toweling down upon the skin where the original application of the wrapping has failed to do so, making the contact as perfect as possible. The limb is then ready to be placed in the apparatus, after which it should be again carefully inspected to see that every- thing is in proper position before the heat is turned on. Knee. At first sight the apparatus designed especially for treating this joint would seem to be particularly well adapted for its purpose, but when it is attempted to utilize it practical difficulties present themselves. In this machine the leg is supported by a canvas or denim strip passing from side to side in the interior of the hot air reservoir, upon which it is designed that the posterior surface of the joint shall rest. It will be found that when the perspira- tion starts it will run down and soak into the wrapping next to the popliteal space, and will be confined there by the pressure of the canvas strip under the weight of the leg. Instead of being rapidly diffused off into the air in the cylinder it remains in contact with the skin, and the constant steaming produced will render it impossible to secure the desired intensity of heat without blistering. It was attempted to obviate the difficulty by having two ver- tical supports made, one to be placed at the distal and the other at the proximal end of the apparatus and entirely external to it, upon which the leg should rest. By this means it was pos- sible to do away with the supporting strip inside of the reser- voir and the conditions were considerably improved ; blistering was still uncomfortably frequent, however. Finally, the special knee apparatus was discarded altogether and the general local machine substituted with eminently satisfactory results; much better in fact than those obtained with the one especially de- signed for the joint (Cuts XII and XIII). Other advantages dependent upon treating the whole of the o K >, Technique. 55 limb below the kriee as well as the joint itself, are, first, the greater amount of reflex trophic influence obtained by reason of the greater area of skin exposed, whereby the total number of nerve-endings stimulated is increased two- to three-fold ; and second, the greater rise of temperature producible in the tissues about the joint, hence greater acceleration of metabolism, through the heating of the entire return circulation from the toes upward. Knee joints which it is desired to treat with dry hot air, how- ever, are sometimes ankylosed in the flexed position, which ren- ders it impossible to get the joint into the general local appara- tus ; that specially designed for the knee then becomes the only one available. The joint is wrapped with three thicknesses of Turkish-towel- ing strips for a distance of ten inches above the patellar and the same distance below this point (Cut XI). The foot is then carried through the cylinder until the knee joint is directly above the source of heat and resting upon the hammock. The flexible attachment for closing the distal end is fastened about the limb six or eight inches below the knee and that for the proximal end at the same distance above (Cut XIV). The heat is then turned on and run up as high as the patient's tol- erance will permit, but for the reasons just stated this will rarely be more than 275 F. ; this degree of heat is much less efficient than 350 F. and not infrequently it will fail altogether in pro- ducing the desired therapeutical result. The fact that an efficient special knee apparatus is not at present available, however, is not of as much importance as would at first be supposed. The class of arthritic affec- tions in which the general local apparatus cannot be used for treating this joint is, as will be seen later, that in which local re- pair is best obtained through restorative influence exerted upon the general system, and the body treatment renders the use of local applications unnecessary. When the shoulder, hip, abdomen, lung, or lumbar region is to constitute the field of operation the toweling should be cut in pieces eighteen or twenty inches wide and five feet long ; when folded twice so as to make three thicknesses such a piece 56 Tlierapeutics of Dry Hot A ir. presents an area that is very convenient for use in this situa- tion. It is also well to have on hand three or four pieces of toweling about eighteen inches square for use with those pa- tients who require but a single thickness of the wrappings. Shoulder. When adjusting the wrapping to this region it will be found advantageous to locate it diagonally with a cor- ner pointed down the arm (Cuts XV and XVI) and to com- mence the winding of the retaining tape at the lower end. Although tape does very well for retaining the wrapping in this location yet it will be found that cloth straps one inch wide, furnished with a buckle at one end, and about five feet long will be found more satisfactory in most cases. After the wrapping has been located as above, such a strap is passed around the body immediately below the armpits so as to in- clude that portion of the wrapping which is folded under the axilla, and buckled so that the buckle is posterior and opposite the median line of the back between the shoulder blades. The free end of the strap is then brought over the wrapping on the shoulder close to the root of the neck and pinned to that por- tion of the strap which passes over the sternum. The edges of the wrapping about the upper arm are then drawn together upon the inner side of the arm midway between the axilla and the elbow and pinned together with a safety pin (Cut XVI). By this means, slight, uniform tension is exerted upon the wrapping all over the area to be treated and in all directions, and no constriction of the blood-vessels or other uncomfortable sensations will annoy the patient. As with the knee joint a better therapeutic result can be at- tained if the whole arm as well as the shoulder is subjected to influence and the entire return circulation of the arm heated. When deformities or motile limitation from pain is not pres- ent in such a degree as to prevent carrying the arm away from the body so as to get it into the cylinder therefore, the wrap- pings used should consist of the strips and their application should commence at the finger tips and be extended to the neck. The proximal end of the cloth attachment should then be ad- justed to the patient sufficiently high up to include the shoulder, and the arm rested upon the hammock inside of the apparatus. Technique. 57 The special chair devised by the author and described in Chapter I will be found very helpful when administering a treatment to the shoulder. Hip. The same suggestion as to placing the wrapping ap- plies when the hip is being prepared for treatment, and in this situation also the cloth straps described in connection with preparation of the shoulder will be found better than tape for holding the toweling in place (Cuts XVIII and XIX). Treatment is most conveniently administered with the pa- tient lying on his side upon a couch, the hip to be treated being uppermost. Abdomen. The patient is brought to the edge of the bed, the wrapping placed upon the abdomen, and retained in place by webbing straps one inch broad, long enough to pass clear around the body, and furnished with a buckle at one end ; these are passed about the body one just above another just below the iliac crests. The patient is then turned upon his side facing outwardly from the bed and a pillow placed under the lumbar region, so as to prevent the sagging of this portion of the body due to the projection of the undermost iliac crest. When this position has been attained it will be found that the webbing straps will require readjustment in order that good apposition of toweling and skin may be maintained. It will also be found that the sagging of the abdomen due to the posi- tion has caused a hollow to form immediately under the upper- most iliac spine, into which the toweling will have to be pressed by crowding a napkin under the retaining strap in this situa- tion (Cuts XXVII and XXVIII). This hollow must be carefully watched during treatment and the covering frequently pressed down upon the skin by the hand of the operator, or blisters will sometimes form in spite of the napkin. The Chest Wall and Lumbar Region. The cloth straps used in the abdominal operation constitute the most efficient means of maintaining the necessary contact between wrapping and skin when treatment is to be applied over the lungs or the lumbar region (Cuts XX, XXI, and XXIII). 58 Therapeutics of Dry Hot Air. When the chest wall of a woman is to be treated one of the retaining straps should be passed around the body directly under the breast, so as to press the toweling well down into the hollow formed by the projection of this part of her anatomy. It will be wise to press the toweling frequently against the skin in this situation anyway during the seance, as the occasional impossibility of securing close contact here, even with a well- applied belt, invites a tendency toward blister formation. Amount of Wrapping Necessary. Just the right amount of covering to be employed will be determined by the idiosyn- crasy of the individual patient as regards pro fuseness of perspi- ration, and of the treatment as regards the intensity of heat, etc., but should be as little as is consistent with safety of the integu- ment. At least one thickness, however, should cover every part of the area exposed, and the wrappings should be boiled in soap and water after each application. Apparatus. When the Betz general local apparatus is em- ployed particular care should be exercised to see that the heat carrier entirely covers the hole in the bottom of the cylinder through which the hot air enters, before the treatment is started. It is very liable to become displaced when the ma- chine is moved and when displaced the thermometer reading is absolutely unreliable as an index to treatment intensity ; further, the proper distribution of heat to all parts of the apparatus is seriously interfered with by such displacement. When treating portions of the body other than the extrem- ities, the supporting hammock inside of the apparatus is of no utility and had better be removed from the machine altogether. Administration. After the wrappings have been applied the cloth attachment appropriate to the region which is to be treated should be ad- justed, first to the patient and then to the apparatus, and the heat turned on. The office of the operator during the treatment resolves itself into four functions, as follow : First, attaining, and steadily maintaining a temperature in the apparatus, of appropriate elevation. o JO co o a, a. o K >> Q d cu o O w >> Q o ffi h Q a, 3 o o w * o "H. Technique. 73 Second, changing the air in the cylinder often enough to maintain dryness. Third, guarding against ignition of the wrappings and cloth fittings of the apparatus. Fourth, preventing blister formation. Accomplishment of the first involves merely allowing the temperature to rise steadily until the desired intensity is reached, where it may be maintained by regulating the heat supply. As regards the second, introducing the heated air directly into the cold cylinder will provoke condensation of moisture to such an extent as to necessitate complete ventilation about once every three minutes during the first quarter of an hour. The little valve in the top of the cylinder is not large enough to ac- complish this efficiently at this stage of the application and the object is best attained, unless the valve has been enlarged as described in Chapter I, by slipping from the cylinder that por- tion of the cloth attachment which encircles its upper segment, replacing it again after a few seconds when the air emerges dry. After the machine has become thoroughly heated no more in- convenience will be encountered from this source, and opening the valve in the top of the cylinder occasionally for a minute or two will effect all the ventilation necessary. The best method of accomplishing the third object is to smell occasionally of the air that escapes from the cylinder during ventilation; the odor of scorching cloth will be detectable if danger is imminent. If the cloth does ignite the first thing to do is to turn off the heat, then remove the patient's limb from the apparatus and dispose of the smoldering fabric. If the mischief is taken in hand as soon as the odor of combustion is detectable there will IDC ample time in which to eliminate the difficulty before serious results are precipitated. Attainment of the fourth object will be facilitated if the con- ditions favoring blister formation are borne in mind, as fol- low: First, the presence of an excessive degree of moisture in the air contained in the cylinder. 74 Therapeutics of Dry Hot A ir. Second, failure in maintenance of even and intimate contact between covering and skin, due to inefficient application of the wrapping in the first place, or to movements which have caused wrinkles to form, on the part of the patient. Perspiration col- lects upon areas ~of skin not in contact with the absorbent, and its temperature rapidly rises toward the boiling point. Third, interference with free circulation of body fluids in the part under treatment, as by undue tightness of the wrap- pings, sclerotic changes in the vascular structures, etc. Unless some condition of the patient's tissues is present whereby sensibility is obtunded, a threatening blister will cause him to complain of a " burning " sensation ; the remedial pro- cedures to be employed when such warning obtains, then, would be as follow: First, ventilate the cylinder rapidly by separating from it the upper portion of the cloth attachment; if this procedure does not remove the discomfort in a few seconds the first-mentioned causative condition is not involved. Second, introduce the hand into the apparatus and press the toweling down upon the complaining area of skin, when im- mediate absorption of scalding sweat, and relief if the trouble is due to this factor, will follow. It requires a little practice to execute this maneuver without burning one's hand; the knack consists in getting the hand in on to the part quickly, and quickly out again without touching the sides of the cylinder.. It is wise for a beginner to wear a cloth glove during this and the next-mentioned procedure; it will save him much discomfort and some blisters of his own. Third, introduce the hand into the cylinder and loosen the wrappings about the complaining region ; if they are too firmly fixed to be susceptible of requisite manipulation in this way, re- move the limb from the apparatus and the wrappings from the limb and reapply them more loosely. When sclerotic changes constitute the offending element soaking the sensitive areas in moderately hot water for ten minutes before treatment, as recommended by Ringer, is the only efficient remedy with which I am acquainted. If this does Technique. 75 not obviate the difficulty it will be necessary to treat the patient with a lower degree of heat : individuals exhibiting gangrenous tendencies cannot safely be subjected to more than 200 F. usually. Duration and Intensity of Stance. The local treatment lasts an hour usually; less than this is not enough, and more does not increase the effect under ordinary circumstances. The intensity demanded will vary from 300 F. to 400 F., rarely more or less. Both duration and intensity will vary according to the condi- tions obtaining in the individual case, and will be discussed in their relation to different pathological states in the sections which treat of these states. . After-Care. Wiping the perspiration from the part treated with a dry towel is all that is required under ordinary circum- stances. Wrapping the part in flannel or cotton, as is some- times recommended, is very rarely called for. Conditions ex- ceptional to these rules will be so noted in the sections which treat of the diseases -in which they occur. External Auditory Canal. The writer has had no personal experience with the use of dry hot air in this region, and the following description of the technique pertaining to the Hopkins generators, is taken ver- batim from one of the inventor's articles upon the subject. Management of the Apparatus. " (i) When the appli- ance becomes hot and exit is through a small opening, as in an ear-tip, the temperature of the air is proportional to the rate of flow, or degree of air pressure. Strange as it may seem, the air temperature may be increased one hundred degrees by increasing the pressure five pounds, or conversely, the tem- perature may be decreased by lowering the pressure. This fact enables us to regulate the temperature at will by merely increasing or decreasing the volume of air entering the cylinder. " (2) The air temperature drops very rapidly after the air leaves the exit-nozzle, and in order to secure the maximum heat the part under treatment must be as near the nozzle as possible 76 Therapeutics of Dry Hot A ir. and still allow room for escape of the used air, if a cavity like the ear is under treatment. Preparation of the Patient. " The ear selected for treat- ment is carefully xamined and found to.be perfectly clean and dry. A light pad of gauze (two thicknesses) is placed over the ear and with an ear speculum the gauze is pressed deeply into the canal, leaving only room enough between the tip and the tympanum for the escape of the used air. Administration. " The electricity is then turned on, or the gas ignited (as the case may be) and the compressed air is admitted to the cylinder under about five pounds' pressure. It is well to give a ten or fifteen minutes' seance, increasing the temperature gradually until the limit of toleration is reached. The temperature steadily increases until the heater reaches its generating limit at that air-pressure, and if the patient tolerates the temperature well it may be further increased by raising the air pressure to seven, eight, or even ten pounds, in most cases. One cannot be guided by thermometers in giving these treatments, and hence they are not employed on the new heater described. The only guide which can safely be followed is the individual toleration of the patient. But it is well to remember that the more slowly the temperature is raised the higher temperature the patient can endure without discomfort." " Treatments are best given three times a week for from three to twelve months." GENERAL APPLICATION. Preparation. A loose bath-robe made of Turkish toweling constitutes the best covering to use during the body treatment. The patient may assume any position agreeable to him, but as it is necessary that he remain quiet and not move his limbs about during the application, lying upon the back is pref- erable unless deformities are present which render the posi- tion irksome. Small pillows are placed under the hollow parts of the body so as to give it support without strain. Technique. 79 Boots made of the same material as the robe and coming to the knees are pulled on over the feet ; if the hands are to be included in the application they should be encased in mittens of Turkish toweling. The robe is then pressed down between the legs and arranged so as to hug the skin closely, and the patient directed not to move his legs about after this has been done. Enough medium-sized Turkish towels are then spread over the feet, legs, and abdomen to form three thicknesses, the apparatus closed by dropping the curtain or curtains, and tuck- ing them in closely about the patient. The inside of the appa- ratus should then be inspected to see that no towel or other in- flammable object has dropped into it, and the heat turned on. Just the right amount of covering to be used will be deter- mined by the idiosyncrasy of the patient as regards profuse- ness of perspiration and nervous sensibility, and of the appa- ratus as regards the degree of heat used in the treatment, etc., but should be as little as is consistent with the safety of the integument. Very frequently the robe alone, which consti- tutes one thickness, will be sufficient; in other cases it will be necessary to cover a portion only of the body, as the feet, ab- domen, or thighs, with the extra towels. The patient's sensa- tions are a pretty safe guide in the matter. Administration. The body area exposed to the heat should usually be the feet, legs, and abdomen up to a point midway between the umbilicus and the nipple line, but it may be extended so as to embrace the whole body up to the neck. The factor which determines whether or not the whole body up to the neck shall be subjected to influence is the degree of response obtained from the nerve centers during the seance, and this also governs the length and intensity of the application. Different individuals exhibit different degrees of suscepti- bility to thermic stimulation and each patient must be handled according to his own law. Observation and experience have shown that this factor is tangibly and conveniently expressed under ordinary circumstances by the degree of acceleration of 80 Therapeutics of Dry Hot Air. the pulse and increase in the body temperature which, as we have seen in the preceding chapter, accompany its applica- tion. The modifications in the character of the respiratory function exhibit too much irregularity to be of value as indices of responsiveness to stimulation. The pulse and temperature then being adopted as guides, it becomes necessary to know the degree of acceleration and in- crease, respectively, which must be attained in order that the amount of deep reflex response which will produce the best results may be known to have been induced, and from a study of four thousand body treatments given under my personal supervision I have adopted, as a working rule, the plan of treating the patient until his pulse-rate has increased to 120 beats per minute, or his mouth temperature is 2 degrees F. above the normal. One of these modifications will be attained first in one patient and the other in the next perhaps, but the attainment of either one usually means that a sufficient influence has been secured and that the time has come to stop the treat- ment. This rule is of course subject to modification according to the conditions surrounding the individual case. I will say here that the mere induction of perspiration, how- ever profuse, is not an indication that a requisite degree of influence has been secured ; comparatively low degrees of heat will often do this. What we want is the deep reflex response, hence the necessity for intelligently thorough treatment. Pa- tients not treated up to this point do not get their due in the way of benefit, and if it is carried much farther the nervous system ordinarily shows signs of over-stimulation which is nearly as bad. Sometimes the application will be completed in fifteen min- utes, sometimes it will require an hour. When acceleration of pulse and increase of body temperature, are already present, as with some acute febrile conditions, this rule, of course, possesses no value and the general effect upon the patient's nervous system must govern duration and inten- sity, care being taken not to over-stimulate. Phenomena sometimes induced during treatment and which demand attention are nausea or retching, faintness, laryngeal Technique. 81 cough, oppression of breathing, headache, cranial throbbing, ringing in the ears, uncertainty or partial loss. of vision, and mental confusion. The first four are evidences of hyper-ex- citability of the nerve-centers and are ordinarily met with only in hysterical subjects; the occurrence of the others indicates cerebral congestion and usually means that the limit of treat- ment duration and intensity, consistent with the patient's best good, has been reached. All of these phenomena are evidences of relatively excessive stimulation. The remedy consists of the application of an ice-cap to the patient's head, which, with moderate fanning of the exposed portions of the body, will usually take care of the situation per- fectly. If the symptoms persist in spite of these remedies the heat should be turned off, the patient cooled, and at the next seance the temperature should be run up more slowly. I have seen but one patient who could not take the limit if handled well and he was a victim of angina pectoris ; the pain was al- ways provoked when the pulse-rate reached no, but it also always subsided kindly as soon as the heat was turned off and the pulse-rate had lessened. Water may be given at any time during the treatment in dessert-spoonful doses every thirty seconds if the patient devel- ops thirst, but should not be administered in large quantities at once. Prevention of Accidents. As regards scalds, burns, etc., the same causative factors, cautions, and means of prevention apply here as were mentioned when administration of the local application was considered, and to avoid repetition the reader is referred to that section for this information. If changing the air or pressing the covering against the skin does not relieve the burning sensation, open up the apparatus and spread an- other towel over the complaining spot. Xo matter what appa- ratus is used, if the heat is intense enough blisters are liable to obtain, and constant care should invariably be exercised. The management of the toes during a body treatment, how- ever, sometimes assumes a prominence which renders it worthy of special mention. The first thing to do when a patient com- plains of discomfort affecting these members is to change the 82 Therapeutics of Dry Hot Air. air in the apparatus, which will dispose of whatever steam may have collected, and direct the patient to move his toes gently backward and forward against the wrappings, but without raising his heels or knees from the couch. If this procedure does not remove the difficulty, open up the apparatus and loosen the wrappings about the suffering mem- bers ; this measure will always prove effective unless some mechanical interference with the circulation of the parts, such as atheroma, sustains a causative relation. If the last-mentioned causation is responsible, soaking the feet in moderately hot water for ten minutes immediately be- fore treatment, as recommended by Ringer, will sometimes pre- vent the annoying sensation. If it persists in spite of the use of all of these meas- ures, however, it will be necessary to resort to the radical plan of treating the patient with his feet outside of the cylinder entirely, the curtains closing the pedal end being tucked closely about his ankles. Leaving the feet outside does not detract in the least from the efficiency of the treatment even when the disease process is located in these members. As has been stated when consider- ing the physiological action of the body treatment, its influence " is predominantly reflex through the sympathetic and spinal nerve centers," hence the profundity of that influence is directly proportional to the number of nerve-endings exposed to the thermal stimulation; the number of those present in the skin of the feet bears such a small proportion to the number present in the skin of the rest of the body that practically it may safely be disregarded in this connection. Clinically I have never been able to perceive that it made any difference whether the feet were inside or outside of the apparatus, except in so far as that it was possible to treat the hyper-sensitive patient with a higher degree of heat when the feet were outside, hence modification of metabolism was more marked. With patients in whom atheroma is present, and is threaten- ing, or has already eventuated in gangrene, the desirability of preserving the toes from blistering is urgent. Under these conditions any traumatic solution of integrity in threatened Technique. 83 tissues is liable to inaugurate the gangrenous process, and my appreciation of that fact has been rendered poignant from hav- ing had the misfortune to see it demonstrated in my own prac- tice. A man seventy years old was under treatment for exten- sive senile gangrene of one foot, the other being unaffected. The great toe of the sound foot was blistered while undergoing a body treatment at 300 F., and gangrene became established in the blistered area in about a week ; this experience led me to adopt the practice of never treating the feet of a patient exhibiting gangrenous tendencies at a temperature exceeding 200 F. I have seen patients with such tendencies in whom sensibility was so obtunded that they would blister without having ex- perienced the warning of discomfort at all, hence it is very necessary to handle these cases with the utmost circum- spection. It is, however, very desirable to induce the full physiological effect of the measure upon them and leaving the feet outside renders it possible to apply the agent as energeti- cally as may be desired. The other portions of the body never give trouble of this sort that cannot be overcome in some of the ways previously suggested. Intensity and Duration of S6ance. It is believed by some operators that as long as the requisite increase in the body temperature and acceleration of the pulse-rate are secured, it does not matter, as far as the therapeutical effect is con- cerned, whether the patient is treated for a long period of time with a low degree of heat (250 F.) or for a short period with a high intensity (375 F.). The writer's experience has not led him to concur in this conclusion, neither does it seem to him that the philosophy of the position is well founded. Experience shows that exposure to a low degree of heat (200 to 250 F.) requires a much longer time in which to produce the requisite modifications in the body temperature and pulse in the majority of cases, and that in some it is absolutely impossible to attain them at all with low intensities. It also shows that physical exhaustion which sometimes lasts for many hours not infrequently follows treat- ment so administered. Further, those who advocate this form 84 Therapeutics of Dry Hot Air. of administration also advocate following the dry hot air application with a cold douche, which indicates that a satisfac- tory degree of vital stimulation does not ordinarily result from the long exposure to a low degree of heat. It is also this class of observers principally who incline to the belief that the beneficial effect of dry hot air applications is confined to the results of hyperidrosis and superficial hypersemia. On the other hand, when the treatment of high intensity is used, the requisite degree of modification in the physiological phenomena is attainable in about half the time required by the reverse procedure, and it is almost never impossible to secure this requisite degree of modification. Instead of physical exhaustion following the treatment we nearly always observe a marked exhilaration which lasts for hours and renders the use of the cold douche entirely superfluous. As far as actual acceleration of the bodily metabolism is concerned, and entirely aside from the patient's subjective sen- sations, I would say that the comparative determinations as regards the urinary constituents made by us up to the present time, indicate a constantly greater degree as resulting from the use of the higher temperature with shorter exposure. If the increased oxidation in the tissues of the body was solely dependent upon the actual increase in its temperature en masse effected by the dry hot air application, then of course the long exposure and low intensity of heat would produce the same acceleration of metabolism as the short exposure and high intensity, provided that the exposure to the low degree of heat was continued long enough to increase the body temper- ature to the same extent; because of the greater total length of time during which some elevation of the body temperature would necessarily be sustained under the latter method, it might be even greater. But it must be borne in mind that this is only one element in the equation, and that probably by far the greater portion of the increase in oxidation (metabolism) is due to reflex stimulation of the spinal nerve centers through thermic irrita- tion of the nerve-endings in the skin. Through this stimula- tion is secured an augmented functionation of the organs and Technique. 85 tissues in which the spinal distributions ramify, hence that form of treatment which effects the greater stimulation ought to produce the greater degree of metabolic acceleration; the ob- servations of the writer would indicate that the application of short duration and high intensity did both. The difference in the effects of these two methods of appli- cation can scarcely fail to make itself evident as a difference in the influence secured upon the trophic and glandular func- tions and the physiological resistance of the patient, and this variation would be important in proportion as the necessity for sharply-defined influence was urgent. In pneumonia, pro- found septic infection, Bright's disease, etc., the question would assume an aspect of prominence ; it has therefore been con- sidered of sufficient moment to justify discussion at some length. After-Care. The management of a patient who has had a thorough body treatment is somewhat important. Our cus- tom is to leave him in the closed apparatus for ten minutes after stopping the heat, then open up the apparatus and allow him to cool, exposed to the air of the room, for twenty minutes. Usually by this time the body temperature and pulse will have returned to the normal. The pulse usually subsides more slowly than the temperature, but the patient should not be allowed to rise until it has nearly or quite reached the rate which obtained before treatment, or syncope is liable to result. One of my early patients frightened me sorely before I had learned this point, by falling in a heap on the floor, unconscious and cyanosed, on her way from the apparatus to the bath ; I had gotten her up too soon. When the pulse has subsided the patient may rise to the sitting posture and see if the exertion causes nausea, faintness, or giddiness; if it does he should lie down again for ten min- utes more. If not, he may slowly and deliberately leave the apparatus and sit in a chair, preferably one which can be in- stantly adjusted to the reclining position if any giddiness or nausea is provoked. If no untoward symptoms appear within three or four minutes he is ready to be taken to the tepid bath, well soaped, rinsed and put to bed. He should then have a 86 Therapeutics of Dry Hot Air. thorough rubbing with alcohol and be left to sleep or rest for an hour, after which he may dress. With patients who are unable to get up and about, the bath will, of course, have to take the form of a " sponge " and may be given either upon the couch of the apparatus or after the patient has been removed to his bed. The sole object of the soap and water bath is removal of the perspiratory accumu- lations ; the alcohol rub which follows is locally stimulant and generally comforting. In some diseases characterized by a marked element of ner- vous debility, as arthritis deformans and various neurasthenic conditions, it is well to prolong the period of rest following the alcohol rub to three or four hours. In General. Frequency of Administration. This factor varies with different diseases and conditions and will be indicated, together with advantageous modifications of the technique, in the sec- tions which treat of these diseases. Intermissions in Treatment. In chronic diseases, as arthritis deformans or chronic nephritis, it is desirable to sus- pend active treatment at intervals after the patient has once been gotten thoroughly under influence, and allow his natural vital powers to carry on their work of their own stimulated volition as long as recuperative ability is manifest. In the majority of disease processes a patient is able to recover his health only through the agency and by the exercise of these powers, and dry hot air applications simply augment them, thereby invest- ing the various elements of the organism with the capacity for more vigorous functionation. After such functional augmen- tation has once been induced then, it is just as well to let mat- ters alone until the physiological processes manifest the need of more help. Most patients are also susceptible of being benefited by a change in their surroundings when such change does not involve disagreeable or detrimental conditions, and when one has been treated in a sanitarium for weeks or months, as many of them will have to be if they get the most out of the thera- Technique. 87 peutical regime, a subjection to different psychological influ- ences will frequently do much to intensify and perpetuate the restorative tendencies of the actively-applied remedial measures. Burns. A proper acquaintance with the technique and ade- quate attention paid to its execution, will render severe burns, scalds, or other grave accidents entirely unnecessary of induc- tion under all ordinary circumstances. Such lesions as do occur pre'sent no pathological features not present in the com- mon blister except that they are usually considerably deeper; ordinary surgical treatment is all that it is necessary to apply for their cure. Centra-Indications. This phase of our subject will have to be investigated fur- ther, clinically, before much can be said of it. As we have seen, the influence of this agent under judicious administra- tion consists of a pure and simple stimulation of normal physio- logical processes without pernicious reactive manifestations, which therefore results merely in accentuation of normal me- tabolism and of the natural constitutional resistance against agencies or conditions which threaten the well-being of the organism. Theoretically, then, it would seem that it ought, upon general principles, to be useful in almost any pathological condition characterized by impairment of physiological func- tion ; practically, in our own experience, the inference has ap- peared to be very well justified, almost no centra-indications that would stand the test of clinical investigation having been ascertained. Malignant disease would seem to offer an unfavorable field for exercise of the ' activities of the local application because of the effect of such activities in stimulating cell growth; I know of no clinical data that furnish reliable information upon this point, however. A recent cerebral hemorrhage would seem to constitute a condition in which it would not be best to invoke the char- acteristic influences of the general application ; here again, how- ever, I know of no instance wherein the hypothesis has been put to the test of trial. 88 Therapeutics of Dry Hot Air. Atheroma and Irregular Pulse. The belief entertained by many that patients with atheromatous arteries or irregular pulse should not be subjected to the body treatment, is a fallacy. Clinical observation justifies the statement that atheromatous arteries are softened and rendered more functionable by the use of this measure, through absorption of lime salts deposited in their walls and, at least partial, regeneration of normal con- nective tissue elements ; we have repeatedly treated individ- uals who have had previously one and two cerebral hemor- rhages with none but beneficial results. In treating patients exhibiting atheromatous phenomena it is well to run the heat up slowly during the first three or foui seances, watching the effects carefully meanwhile and sus- pending further increase in treatment intensity when the heart and carotids begin to labor unduly ; but we have never encoun- tered the slightest cause for anxiety with them any more than with others when carefully handled. Irregularity of the pulse coming on during the treatment of such a patient should always be a signal for the exercise of watchfulness and usually for the termination of the appli- cation. Valvular Heart Lesions. The modifications of the circu- latory phenomena attributable to the general dry hot air appli- cation are so similar to those brought about by the administra- tion of nitro-glycerine, sparteine, strychnia, etc., that the position involving objection to its employment with patients exhibiting valvular heart lesions becomes obviously untenable ; this subject may therefore be dismissed without further con- sideration. Pyrexia. A glance at the list of diseases in the treatment of which this agent renders valuable service demonstrates that elevation of the body temperature interposes no valid objection to its administration. Fever, per se, is merely a secondary result of a primary pathological factor ; its degree is dependent upon the intensity of the causative process and the degree of reactionary susceptibility exhibited by the individual patient, hence its treatment should be that of the condition producing it. Technique. 89 The phenomenon of pyrexia is believed by some observers to be directly dependent upon irritation of the sympathetic nerve centers by toxic bodies elaborated by the active primary pathological factors; by others as due to impairment of the heat inhibitory centers traceable to the same cause; and by still others it is believed to constitute an expression of nature's effort to rid herself of disability by accentuation of the normal metabolic (oxidative) processes, the increase in heat produc- tion being the logical physical result of accelerated chemical reactions, and energy transformation as represented by aug- mented reflex functionation of nervous structures. If the last-mentioned explanation should ultimately prove to be the true one, and there is good reason for such belief, it is obvious that the remedial agent under discussion will be the most useful as well as the most logical means of combating secondary febrile phenomena now known; it is a pure and simple but powerful accelerant of normal physiological pro- cesses and being such merely assists in and augments the in- stinctive natural effort of the organism to regain its molecular, structural, and functional integrity. Whatever explanation is accepted the palpable therapeutic indications suggested by modern conceptions of the direct etiology of fever, consist of measures tending to increase elim- ination of toxaemia and the functional vigor of the disturbed nerve centers; the general dry hot air application is extremely well calculated to accomplish both of these objects. Another fact that may be significant in this connection, is that patients exhibiting febrile movement usually express them- selves as being comforted and tranquilized by a dry hot air application ; they welcome instead of resisting it. At first thought it would be supposed that such an application would be intolerable to a patient who is already suffering from excessive elevation of temperature, but the actual result of the application tends to confirm the reasoning set forth in a preceding section as to the relative effects of heat and cold as regards the harmony or antagonism which they respectively exhibit, with reference to the natural efforts by which the organism endeavors to rid itself of disability. Future investi- 90 Therapeutics of Dry Hot Air. gation appears to promise interesting developments along the lines herein suggested. Hyper-Pyrexia. In this peculiar and interesting condition, wherein the general bodily metabolism seems to run amuck, dry hot air has not yet been tried as far as I know. The condi- tion is supposed to be caused by exhaustion of the heat inhibi- tory centers brought about by an intolerable degree of irrita- tion exercised upon them by toxic bodies in the blood. The only remedy that has hitherto proven itself of much use has been the application of cold to the general surface of the body, which has been supposed to act by reflex stimulation of the exhausted nerve centers and by checking the excessive metabolic activity through the abstraction of heat. As we have seen, when considering the physiological action of dry hot air, there is a vital difference between the effects of hot and cold applications and as a rule this difference favors the employment of heat rather than cold. Whether or not this is the case as regards hyper-pyrexia is a matter for future in- vestigation to decide. As was also explained in the previous chapter .dry hot air applications of appropriate intensity accom- plish their stimulation without imposing any initial strain upon the vital powers ; in the condition under consideration these powers are already strained beyond their limit of endurance and if the reinvigoration could be secured without the pro- duction of additional antagonistic tension it would seem to be desirable to so secure it. Present knowledge and logic, therefore, would seem to in- dicate that investigation of the effects of dry hot air in hyper- pyrexia would be justifiable as well as interesting. Local Infective or Inflammatory Foci. It is sometimes stated that dry hot air applications to localized inflammatory processes of any sort are dangerous and likely to transform the local into a general pathological condition. I have never heard a logical defense of this position, I have never heard of an authentic case wherein there was any satisfactory evi- dence that such a result was properly attributable to dry hot air, and in the hundreds of such treatments that I have adminis- tered myself and have had administered under my supervision Technique. 91 to such cases, I have never in a single instance, seen the slight- est reason for believing that dry hot air was guilty or capable of precipitating such a disaster; I am therefore free to state my entire disbelief in the existence of any cause for apprehen- sion in this respect. Until experience has widened, however, it will be wise to exercise a judicious conservatism when invading pathological fields wherein the actual effects of this very potent agency have not yet been investigated, the capacity of a measure for the production of good being sometimes only equaled by its evil tendencies when applied to improperly selected conditions. We will now consider the practical application of dry hot air to those diseases in the treatment of which it has been demon- strated to be of value, and the order in which these diseases are considered will be found to coincide approximately with the degree of importance which the agent assumes in their man- agement. CHAPTER IV. SPRAINS. Modifications of Clinical Conditions producible unth Dry Hot Air. Local Application. First, immediate relief of pain, which relief can be rendered practically permanent by repeating the treatment as often as the pain becomes troublesome. Second, rapid removal of exudate. Third, a rapidity of repair which exceeds that attainable with any other agent noiv known, and by reason of ivhich, gen- eral systemic impairment due to pain or lack of exercise from confinement to the bed, chair, or house never supervenes. Gener.al Application. Hastening of the reparatire process in all cases, and rapid removal of general debility in old cases. RATIONALE OF THERMOTHERAPY. Pathology and Symptomatology. A sprain consists sim- ply, in uncomplicated cases, of traumatic solution of the con- tinuity of soft issues about the affected joint, accompanied by severe pain and more or less impairment of function ; a strictly local condition which is not inherently capable of precipitating secondary phenomena which threaten the integrity of the organism at large. Therapeutic Indications. First, to relieve the pain. Second, to so influence the trophic functions of the affected part as to secure the quickest possible repair. Third, to secure absorption of the exudate. Local Application. Theoretically the physiological influ- ence of the local dry hot air treatment should be most ex- 92 Sprains. 93 quisitely applicable here ; practically, clinical experience demon- strated the validity of the deduction. As a matter of fact if a sprain is gotten under treatment by this agent within four or five hours after the injury has been sustained, the pain will be relieved within half an hour and all traces of the trouble will frequently have disappeared within forty-eight hours. If the case has been running on for two or three days, on the other hand, and exudate is present to any great extent complete removal of disability will require from one to three weeks ; the pain, however, is susceptible of the same immediate relief as in the early cases. Although such results may appear magical at first thought, yet when the subject is considered from an analytical stand- point it is recognized that the agent produces its results in the same way as does every other successful treatment of the con- dition, viz., through its action upon the circulatory and trophic functions. The greater rapidity of repair obtained and the more effectual relief of pain, are due merely to the greater profundity of its physiological action, and its general influence in these directions is beautifully exemplified by its effects in this condition. It is only necessary to compare the course of events marking recovery from a sprain under ordinary management, which not infrequently extends over a period of six or eight weeks, with those just outlined in order that the immense advantages exhib- ited by dry hot air in the treatment of the condition may be appreciated. If a sprain is complicated by bony fracture the local appli- cation will usually relieve the pain somewhat ; less frequently it will not relieve it at all ; and sometimes it makes it worse. If the treatment fails to produce practically complete relief of pain it is almost positive evidence that such fracture coexists. General Application. A sprain is usually sustained while the victim is in good health, and as the lesion manifests no inherent tendencies toward impairment of the general metabolic functions the body treatment is rarely called for in recent cases. In those of some standing, however, wherein the central ner- vous system is feeling the evil influence of long-continued pain 94 Therapeutics of Dry Hot A ir. and loss of sleep, in patients exhibiting a low grade of vitality, or when repair has become sluggish from any cause the general application is of the greatest assistance. ILLUSTRATIVE CASE. Mrs. R. H., aged sixty-three years. Patient had slipped on a curbstone during the afternoon of May 26, 1900, spraining her left ankle. I was asked to see her in the evening, at which time severe throbbing pain was constantly present, a swelling about the size of a butternut was evident just below and an- terior to the external malleolus, and the tissues in this region were so sensitive as to be entirely intolerant of any but the gentlest of manipulation. She was unable to put her foot to the floor because of the resultant excruciating exacerbation of the pain. A local dry hot air treatment was administered at 450 F. for an hour, which entirely relieved the pain, and she was put to bed without any bandage or other local application to the foot. May 27th, 1 1 A. M. Patient had been free from pain during the night and had slept well. The swelling had diminished a good fifty per cent., and only deep pressure upon the injured tissues elicited protest. Stepping upon the affected member caused her slight pain and holding it suspended downward provoked a dull, throbbing ache. Another local dry hot air treatment was administered at 485 F. for an hour, an elastic bandage applied about the ankle in such a way as to give support to the lacerated struc- tures and the patient allowed to be up and about at her pleasure. May 27th, 10 P. M. Ankle had been entirely comfortable all day. Swelling had entirely disappeared, but some tender- ness upon deep pressure was still observable immediately below and anterior to the outer malleolus. The third and last dry hot air application was administered and directions given to apply the elastic bandage again next morning before she left her bed. I saw her again during the morning of May 29th, or sixty hours after the first dry hot air treatment had been given, and all signs of the injury had disappeared ; the elastic bandage was discarded and the incident closed. TREATMENT. Local Dry Hot Air Application. A sprained joint rapidly becomes extremely sensitive to manipulation and when one Sprains. 95 comes under treatment, however early, the slightest movement will usually cause excruciating pain. The wrappings should therefore be applied with the utmost gentleness and when pressing them against parts that complain during administra- tion this exquisite sensitiveness should be borne in mind. The application should be continued for an hour and the degree of heat employed should not be less than 350 F. ; in some cases it will need to be pushed to 450 F. If the joint is superficial, the patient not obese, and little oedema present 350 F. will usually be sufficient; if the impaired structures are covered by large muscles or a thick layer of adipose or cedematous tissue, on the other hand, from 400 to 450 F. will be required. After the seance, if the patient desires to move about the joint should be enwrapped by an elastic stockinet bandage, so applied as to support the ligaments tension upon which causes pain. When sitting or lying down no bandage is necessary but the joint should be kept elevated; observance of this latter point will frequently prevent the pain from becom- ing troublesome after the first treatment. In old cases relief of pain is just as prompt but repair is slower in proportion as exudation and secondary changes in the tissues are extensive. The local application should be made twice daily anyway and oftener if return of pain demands it. General Dry Hot Air Application. The technique is that usual to this procedure ; it may be applied every other day until three applications have been given and every third day there- after if its continued use should be necessary. Additional Remedial Measures. When dry hot air is applied early any other measure will very rarely indeed require consideration at all, but in older cases other agents are useful in combination with it. Mechanical vibratory stimulation, the electrical currents, massage, and alternating hot and cold douche, applied daily in alternation with the thermal agent, one in the morning, another at noon and another at night, are efficient in the order 96 Therapeutics 0f Dry Hot Air. in which they are named; the two first-mentioned when used alone sometimes will produce results that rival those obtain- able with dry hot air. Liniments are uncalled for, and useless except as lubricants, when dry hot air is available. CHAPTER V. RHEUMATISM. Modifications of Clinical Conditions producible with Dry Hot Air. Local Application. First, immediate relief of the pain however severe, which relief may be rendered practically continuous by repeating the treatments as often as the pain becomes troublesome, every four hours if necessary. Second, shortening of the duration of the disease, the same usually lasting only from five to ten days when dry hot air is thoroughly administered in combination with well chosen drugs. Third, lessening of the likelihood of cardiac involvement, be- cause the rapid control obtained over the condition diminishes the time period during which the infection threatens struc- tures other than those originally involved. Fourth, lessening of the number and quantity of medicines which it is necessary for the patient to ingest, because of the increase produced in the intensity and efficiency of their action at the seat of infection. General Application. Lessening of general systemic toxcemia and intensification of the physiological resistance of the organism as a whole. RATIONALE OF THERMOTHERAPY. Etiology, Pathology, and Symptomatology. In the early seventies of the century just closed McLagon of London, Eng- land, published his belief that rheumatism was a disease caused by a specific " Materies morbi " circulating in the blood, and that salicylic acid as a specific curative agent sustained much the same relation to it that quinine was believed to sustain 97 98 Therapeutics of Dry Hot Air. to malaria; that as a disease it was in many ways and to a considerable degree analogous to malaria. Although the an- nouncement was met by the same overwhelming skepticism and derision that has so strangely been heaped upon nearly every great discovery in the medical world since the dawn of history, yet the conviction of its truth, at least as far as the etiological element is concerned, has steadily gained ground until the profession to-day is almost ready to look upon the infectious origin of the ailment as an established fact. Discussion of the etiological ramifications per se does not come within the scope of this work, and those who desire to pursue the matter further will find a masterly and convincing exposition of this view of the subject in the second volume of the " Twentieth Century Practice of Medicine," in the section devoted to this somewhat remarkable and most interesting disease. We are somewhat concerned, however, as will be seen later, with the latter part of the McLagon contention, viz. : that salicylic acid is as much of a " specific " in the treat- ment of rheumatism as is quinine in that of malaria. The pathology present consists of fluid effusion into the sub- cutaneous tissues overlying the affected joint, the soft tissues immediately about the joint, and to a limited extent into the joint cavity; and an inflammatory process involving these structures which is intense in its nature and exhibits the weli- known characteristic that, no matter what the degree of sever- ity, it never eventuates in suppuration. After an attack of true, uncomplicated rheumatism has subsided the affected joint structures spontaneously and completely resume their normal condition. Fibrous adhesions have commonly been looked upon as forming a prominent element in the pathology of " chronic " rheumatism, but modern clinical 'observation and knowledge indicate that this condition is rarely, if ever, met with as a post- rheumatic lesion and that when it is so alleged the diagnosis of the original trouble should be subjected to close scrutiny. The joint pathology is accompanied by excruciating pain in the affected part, which is increased by motion and manipula- tion and probably due to pressure upon the nervous structures, Rheumatism. 99 the presence of which, in turn, could easily be traceable to cir- culatory stasis in the part ; and a condition of general systemic toxaemia evidenced by a moderate degree of febrile movement which is entirely irregular in its course, general malaise, and a profuse sour perspiration. An undetermined etiology and a pathology so lacking in significant features, as far as indicating what direction treat- ment should assume is concerned, furnish us very unsatisfac- tory grounds upon which to build a rational therapy ; we have therefore to depend principally upon the symptomatology and empirical knowledge for the evolution of a plan of manage- ment, and a study of the symptomatology would suggest direct- ing our efforts toward the attainment of the following objects : Therapeutic Indications. First, relief of the pain, which symptom is probably due to circulatory stasis. Second, removal of the local inflammatory conditions and restoration of joint function. Third, reduction of the general systemic toxaemia. Local Application. The palliative influence of hot applica- tions upon the pain of rheumatic inflammation has long been a matter of common knowledge and it was this fact that first led me to employ dry hot air in treating this affection; if mild degrees of heat would give some relief greater intensities might be productive of much benefit. The results which followed its use so far exceeded my expectations as to border upon the mar- velous. Patients who were suffering indescribable torment were transported to a condition of ease and comfort in half an hour and would sometimes have recovered entirely in a few days ; mechanics who had been unable to work for months and in whom the general condition had been much impaired by the disease were restored to health and enabled to resume their occupations in two weeks. To one who is not in the habit of treating rheumatism with this agent the effects obtainable are absolutely beyond belief unless personally witnessed. Professor Wood of Philadelphia voiced a sentiment common to thermotherapists when he made the remark that the results of dry hot air applications to some joint conditions were " almost miraculous." ioo Therapeutics of Dry Hot Air. At the time of my original observations along this line I had not expended much thought upon the physiological action of the agent, but when we study this in connection with the caus- ation of rheumatic pain we are no longer surprised at its effi- ciency in relieving the same; it is simply a manifestation of the powerful influence of the local dry hot air application in overcoming local circulatory stasis whereby pressure upon nervous structures is relieved. How much, or whether much of the effect is due to stimulation of local oxidation processes through the raising of the temperature of the part en masse, or to local elimination of toxins cannot at present be definitely stated; removal of circulatory stasis, however, would seem to be sufficient to account for the result without having to assume that any other factor is active. That the influence upon the local conditions other than stasis is, however, profound is evidenced by the facts that great immediate improvement in the general condition, which goes on to rapid recovery, usually follows the administration of local dry hot air applications if an appropriate salicyl compound is given in efficient dosage along with the thermal agent; that such improvement is much greater and recovery much quicker than when the salicyl is administered without the dry hot air; and that a convalescence that is dragging along unsatisfactorily under salicyl treatment alone will be accelerated and rapidly eventuate in full recovery when the thermal element is added to the therapeutical regimen. The relief of local stasis and pain is not sufficient to account for these phenomena; they are explicable only upon the assumption that influence has been exerted, either directly or indirectly, upon one or more of the primary causative factors. What these factors are or in what way they respond to this influence cannot be stated until the etiology of the disease has been conclusively ascertained. Conversely to the foregoing it may be as well to state here, as elsewhere, that dry hot air applications without salicylic acid do not constitute a satisfactory management for rheumatism in any large number of consecutive cases. It will almost always relieve the pain temporarily, but it cannot be depended upon to cure the disease. Rheumatism. 101 The preceding paragraph would suggest the query " Why will not dry hot air alone cure rheumatism? If, as is all but proven, this ailment is of microbic etiology it resembles, to some extent, local septic infection, and it would naturally be expected that the agent ought to exercise much the same power over rheumatism that it does (as we shall see in the following chapter) over septic infection ? " We can only answer that the infective agent of rheumatism differs from other pathogenic germs. We have already noted one great and important peculiarity, viz. : that the inflammatory process of which it is provocative never eventuates in suppu- ration ; if it differs in one particular it may safely be assumed to be capable of differing in others, and the extent and number of its variations cannot be estimated until it has been isolated and studied. Whatever the future may divulge as to these points the fact which concerns us in this connection remains, viz., that the simultaneous administration of salicyl compounds is necessary to-day, in order that dry hot air may produce its most effective influence upon true rheumatic inflammation, and it will be helpful to consider briefly at this point the relation sustained by this drug to the problem under discussion. Is Salicylic Acid a " Specific " for Rheumatism? The claim that this substance is as much of a specific in the treat- ment of rheumatism as is quinine in that of malaria, is as bitterly opposed to-day by many as was the claim for an infec- tious causation of the former disease thirty years ago. In order to decide this point definitely it would first be necessary to understand the modus operandi by which the well-known influences of quinine upon malaria and of salicylic acid upon rheumatism are brought about. It was formerly supposed that the curative effect of quinine upon malaria was due to a toxic influence exerted by this sub- stance upon the plasmodium, either directly or by modification of its pabulum ; the advocates of the McLagon contention con- sidered it probable that salicylic acid acted in an analogous manner upon the specific mat cries morbi of rheumatism. Recent radiological studies by King, Busc, Halberstaedter, L, 1C I A.K v_ L.L LC ixUHL LUE^.ii. k fc IO2 Therapeutics of Dry Hot Air. Dreyer, and others, have, however, given rise to the concep- tion that the curative power of quinine may be due to its prop- erty of modifying the fluorescence of the blood rather than to direct toxic action exerted upon the specific infective agent; salicylic acid is also a fluorescible substance, and the McLagon chain of analogy between malaria and rheumatism which first led its author to administer salicin for the cure of the last-men- tioned disease may thus, perhaps, be ultimately furnished with another link. As the facts stand at present we cannot arrive at a positive solution of the problem, but the future seems pregnant with interesting developments along these lines. We are living in an age of rapid progress ; an age that has been characterized by the demolition of theories that for years had been looked upon as impregnably intrenched behind the rampart of truth, and he is a bold man who to-day will say to the enterprising theorist, as Canute said to the sea, " Thus far shalt thou go and no farther." As far as the present discussion is concerned, how- ever, the most important fact upon which the claim for specific- ness of the salicyl compounds has been assailed is, that they fail to cure in many cases, and some significant information bearing upon this point may be gathered by noting some of the clinical aspects of these diseases as regards response to their alleged specific remedies. The belief that quinine bears such a relation to malaria was engendered by the repeated observations of a large number of physicians, which demonstrated that the disease almost invari- ably responded happily to administration of the drug in ade- quate dosage ; many clinicians indeed hold that if a given case does not so respond the diagnosis of malaria must be changed, however well justified in the first place. Now although this belief is so thoroughly established in the medical mind to-day, and it has stood the test of practical experience . for many years, yet occasionally a victim of malaria is encountered who is taking quinine to the point of intoxication and shaking at each regular interval in spite of it. This does not invalidate the claims of the drug to specificness in our minds, however, because we know that the cause of its Rheumatism. 103 failure is inefficiency of assimilation or metabolism somewhere in the economy, and that when this has been corrected the drug will manifest its customary influence ; the difficulty is not that the remedy has proven itself inherently incapable, but that it has been called upon to exhibit its powers under overwhelming inhibitive conditions. If the interfering factor is the liver, a chologogue is administered ; if general debility, strychnia and iron, or arsenic ; then quinine, and the malaria disappears. Another prominent factor tending toward maintenance of the reputation of quinine as a specific for malaria is the fact that remedies which have long been known and commonly used as tonics constitute efficient auxiliary agents for the removal of conditions which interfere with the exercise of its characteristic influence. Still another fact that has been favor- able to quinine in this connection is that many trivial condi- tions which would respond to mild tonic and chologogue reme- dies have in the past been erroneously diagnosticated as " Malaria," hence the drug has absorbed considerably more credit than rightfully belonged to it. As regards salicylic acid, the conditions have been very different. In the first place comparatively few practitioners have given the drug in sufficiently large quantities ; one or two grams of sodium salicylate per day having been called upon to cure when two or three times that quantity should have been given, and inefficiency has, of course, resulted. Second, many stomachs, hearts, and kidneys cannot tolerate sodium salicylate in sufficient dosage to effect the desired result, and although the substitution of salicin will usually overcome this difficulty, it requires to be given in twice as large a quantity (4 to 8 grams per day) as sodium salicylate in order that the same degree of salicyl influence may be secured, and the disadvantage contingent upon this greater bulk has generally resulted in the more irritant substance being em- ployed. Third, although the undeniable inefficiency of salicylic acid in some of those cases wherein adequate dosage was practicable and practiced would naturally first suggest, to follow out the malarial analogy, that impairment of assimilation and metab- IO4 Therapeutics of Dry Hot Air. olism, local or general, was the element of interference, yet the drugs ordinarily used to remove such impairment have not proven nearly as uniformly successful as auxiliaries to the salicyl compounds in the attack upon rheumatism, as to quinine in that upon malaria; the logical inference being that the incapacity of salicylic acid so manifested was inherent in itself. Fourth, many conditions exhibiting painful joints, nerves, or muscles as symptomatic phenomena, have in the past been diagnosticated as rheumatism which were not rheumatism at all, and no matter how specific the drug might be against rheu- matism it would not of course be expected to acquire any last- ing laurels under such circumstances. Lastly, there are very few other painful conditions that would be likely to be confounded with rheumatism and which would respond happily to anti-rheumatic treatment, hence the drug would not be accredited with curative results for which it was not responsible. It becomes apparent at once then that the opponents of the McLagon contention as to the specificness of salicylic acid in rheumatism have had good evidence upon which to base their position, and as much of this evidence is the result of practical experience it is the most difficult sort to disprove. The evolu- tion of salicyl compounds which are not intolerable to the stomach, heart, and kidneys, whereby adequate dosage has been rendered possible, is doing away with much of it; increase in diagnostic knowledge and ability is doing away with a great deal ; and it would seem probable that the advent of dry hot air as an efficient auxiliary measure for the improvement of local and general metabolism and assimilation might remove the rest. Be that as it may, the fact is readily demonstrable to-day that the extinction of almost any attack of true rheumatism, how- ever severe, can be as satisfactorily and positively accomplished by the proper administration of salicylic acid supported by dry hot air treatments as can an attack of any other disease by its appropriate specific drug management, not excepting malaria. That the thermal agent is only entitled to credit as an auxiliary Rheumatism. 105 measure through which to remove conditions that interfere with the exercise of the characteristic salicyl influence, is proven by the fact that few cases respond satisfactorily to dry hot air when this agent is used alone. The results of the employment of dry hot air in the manage- ment of rheumatism then may possibly forge still another link for McLagon's chain of analogy and constitute another bit of confirmatory evidence as regards his contention that salicylic acid is a specific remedy in the treatment of this disease. General Application. The physiological action of this measure at once suggests its employment with patients who have become debilitated by a protracted attack of the disease, or when systemic toxaemia is pronounced; the validity of the inference is confirmable by practical experience. DIAGNOSIS. The correct diagnosis of a condition presenting clinical phe- nomena of an apparently rheumatic nature is a matter of the first importance, and as anti-rheumatic treatment is not only futile but occasionally positively injurious, in some conditions closely resembling this disease, the diagnosis should be made before treatment is instituted. The amount of undeserved opprobrium that rheumatism has been made to bear may be inferred from the fact that probably three-fourths of the cases that were diagnosticated as rheumatism previously to three vears ago, were not rheumatism at all, and further, involved the practical point of being disease processes that would not respond happily to anti-rheumatic therapeusis. The more important conditions from which it is to be differ- entiated are as follow : arthritis deformans ; neuritis ; neural- gias; myalgias; osteomyelitis; tubercular, syphilitic, gonor- rheal, and traumatic osteitis and periosteitis; and non-rheu- matic synovitis and myositis, which last is of rare occurrence, but sometimes offers a diagnostic problem which may be puz- zling in the highest degree for a short time. Pressure from tumors, especially those occurring in the retroperitoneal lymphatics and which involve the nerve trunks and plexuses in these vicinities, orthopedic deformities especially flat foot, 106 Therapeutics of Dry Hot Air. and the occupation neuroses in their earlier stages, deserve a much greater amount of consideration in this connection than is generally accorded to them. The two first- and two last-mentioned conditions are con- cerned in by far the greater number of diagnostic errors, and in these also early recognition is of great importance. The diagnosis of true inflammatory rheumatism is so well set forth in the ordinary text-books and the clinical picture is so familiar that further consideration in this volume is uncalled for. ILLUSTRATIVE CASES. Acute Rheumatism. I was consulted by Mr. G. L. M., forty-five years old, February 28, 1899. He had had inflam- matory rheumatism two or three times before, the last attack preceding this one having occurred in 1891, at which time he was ill for three months, both ankles and the right great toe joint being involved. His father had suffered frequently and severely with inflammatory rheumatism (?) and his mother had been gouty ( ?). When I was called he had been suffering for two weeks, the left hip being the part involved, and during this time he informed me that he had been taking salophen and alkalithia constantly, with no result. The symptoms had increased rapidly in intensity during the preceding two days, and he had had no sleep for twenty-four hours and very little for forty-eight hours. Joint was extremely sensitive to manipu- lation and pressure. Dry hot air was applied locally and the pain was entirely gone in twenty minutes. At the conclusion of the treatment the joint could be manipulated within certain limits without any pain. I requested the patient to call at my office the following morning if he was able. Salophen was prescribed internally, one gram three times a day. He appeared at the time appointed, March ist, reporting that he had experienced no pain after the treatment of the preceding day until this morning on arising from bed, but that since then it had been slightly, but constantly present. He was on his way to business and had " only dropped -in to let me know that he was all right." I persuaded him to allow me to treat him again, but he would not relinquish his intention of attending to his business. I treated him for an hour, with entire relief of pain as before, and he promised to report the next day. March 2d. Patient called this morning, informing me that half an hour after leaving my office yesterday he had suffered from an acute attack of pain, lasting about ten minutes, which Rheumatism, 107 had then subsided, and he had felt it no more until this morn- ing, when, for half an hour, it was quite severe. Another remonstrance as to his continuing to perform his business duties was met by the assertion that to stop at this time would entail financial loss that he was unwilling to sustain, and that as long as he continued as comfortable and as free from pain as he was then he would rather keep about his business and take a longer time for his recovery. He was treated and requested to report the next day. March 3d. No pain since last treatment, but feels a dull soreness in parts, which is growing steadily less. Dry hot air was again administered. Patient desired to stop his salophen, but it is unnecessary to say was ordered to continue. He did not call again until March 8th, when he reported having had slight twinges of pain always in the morning on arising and occasionally during the day, but of steadily decreasing severity since the last treatment. This morning for the first time since the attack began, he had been entirely free from pain of any sort. He laughingly derided me for having desired to keep him in bed and said, as I supposed in joke, that he wasn't " going to take any more of those powders." March nth. Patient had continued to feel so well after his last call that he had carried out his threat of stopping the salo- phen, and yesterday he began to suffer again. Resumed salo- phen, and toward evening grew more comfortable, but this morning pain is again quite severe. Dry hot air gave its customary immediate relief, but patient was going out of town and could not call again for treatment until two days after. March I3th. Reports freedom from pain all day on the nth, but it was present considerably yesterday and this morning. Dry hot air administered with the usual happy result. March I4th. Slipped on a curbstone while running to catch a car yesterday, wrenching the affected hip badly. Suffered from excruciating pain for an hour, which then subsided, leav- ing intense soreness and throbbing which were present this morning. Treated with dry hot air, but pain, for the first and only time, was not entirely relieved, and the patient left my operating room with a slight limp. March I5th. He appeared at my office at 7.30 A. M., report- ing that pain returned quite severely four hours after treat- ment, and had stayed with him pretty sharply ever since. In- sisted that he could not leave his business and remain quietly at home, and I suggested that he be treated three times that day, io8 Therapeutics of Dry Hot Air. to which he consented. I treated him at 9 A. M., at 2 P. M. and 7 P. M., with the result that he kept about his business and had practically no pain. March i6th. Came to my office at 9 A. M., reporting that he had had no pain until eight o'clock after rising from bed, and then only slight dull twinges. Administered dry hot air at 9 A. M. with the usual satisfactory result, and requested him to call again for treatment at two in the afternoon. He did so, informing me that he had had no pain at all since morning, and expressed himself as feeling better generally and locally than at any time since the attack began. Ordered him to come in the evening if he felt the slightest return of the pain. I did not see him again for a week. On March 23d he came to my office early in the afternoon, supporting his right arm with his left, suffering with intense pain in his right shoulder, which he said had commenced about ii A. M. The slightest movement of the affected joint forced him to cry out, and when I had succeeded, with great difficulty and the utmost care and gentleness, in removing his clothing preparatory to treatment, he was shaking like a leaf. I applied dry hot air with the usual result; pain was relieved in ten minutes. At the end of the treatment he could move his arm sufficiently to get into his clothing without assistance, was perfectly free from pain, but could not raise his elbow to within more than three inches of the level of his shoulder. He had had no trouble with the hip since the last treatment, and I will say here that the recovery of this joint was complete and remained so. I directed him to call again for treatment in the evening. At that time he was suffering slightly, but was able to remove his clothing for treatment without assistance. Dry hot air was administered and directions given to call again next morning if he was in any pain at that time. I did not see him again until March 25th, when he called to tell me that he had had some slight twinges of pain during the night fol- lowing the last treatment, but had remained free from it ever since. I requested him to call immediately if any more symp- toms appeared, and to continue the salophen for two weeks. Five days afterward, on March 3Oth, he called, complaining of a dull aching in the right shoulder which I dissipated with one treatment, and that was the last of the trouble. I quote this particular case, not because of the rapidity with which a cure was obtained, but because it is very instructive in this connection when the different phases which it exhibited are studied carefully. Rheumatism. 109 First, it was treated exclusively, as far as dry hot air was concerned, with the local application. Second, it illustrates forcibly the power of dry hot air to rapidly alleviate rheumatic pain. Third, it exemplifies the necessity of accompanying dry hot air applications with appropriate internal medication, as shown by the severe return of symptoms in the same old place on March loth and nth, after the salophen had been prema- turely discontinued. Fourth, when I state that the total length of time during which this patient was under treatment, viz., one month, is longer than that required for the recovery of any other case of rheumatism, however severe, that I have ever submitted to this management, and when we compare this period with that usually required for recovery from an ordinarily severe rheumatic attack under other methods of treatment, it ex- emplifies in a very gratifying manner the power of dry hot air to shorten the duration and lessen the symptomatic intensity of the disease. Here was a severe case in active eruption in a patient ex- hibiting a strongly rheumatic tendency; he kept up and about his business all the time, and yet, in spite of this utter and con- stant disregard of one of the prime essentials to be secured in the treatment of inflamed joints, viz. : rest, the attack was ex- tinguished completely in a month. Not only this, but the patient had been kept entirely free from pain the vastly greater part of the time during that month ; an achievement which could not be claimed as among the possibilities for any other treatment with which I am acquainted, however perfect might be the rest secured. When the patient can be kept at rest it has uniformly been my experience that an attack of acute rheu- matism is extinguished in from five to ten days, whatever the degree of severity exhibited when it comes under treatment, and I have had cases of moderate severity recover with but three applications. Chronic Rheumatism. Mr. J. D., brass worker, 33 years old, was referred to us for treatment by Dr. James Stretch, HO Therapeutics of Dry Hot Air. of Stafford Springs, Conn., and was admitted to the sanitarium November u, 1903. He had been ill with rheumatism for the preceding ten months, which had involved nearly all of the large joints in his body at different times. When he was ad- mitted the disease was manifesting itself by pain and soreness upon movement" in both shoulders, the left being the worse, the right knee and the left ankle, the knee and ankle being some swollen. He was much debilitated. He was put upon aspirin, one gram four times daily, and during the next nine days was given five body dry hot air treatments, four applications of the mechanical vibrator to his posterior spinal nerve roots, five general tonic applications of static electricity, one spinal galvanization, and two applications of the negative pole of the galvanic current slowly interrupted, to his left shoulder. During the last three of these nine days he had been entirely free from pain and joint disability and felt so much better gen- erally that he decided to return to work, against my advice it is unnecessary to state. Four days after his return to work he sustained a sharp return of the trouble in both shoulders. This yielded to aspirin completely in two days, however, and he heard no more of it. This case is particularly instructive because the patient came under our care directly from a large public hospital where he had had several weeks of the best ordinary anti-rheumatic man- agement without positive result. The addition of dry hot air and the other physical measures to the therapeutical regimen, however, produced the above marked and very satisfactory result in nine days. TREATMENT. Five years ago in an article concerning dry hot air, the writer expressed the opinion that a " new leaf " was about to be turned in the history of the clinical results of rheumatic therapeusis, and subsequent experience has justified the infer- ence then noted. It is in this disease that the agent has won some of its most enduring laurels. Its mode of application and the results derivable therefrom are now well defined, and the treatment of the disorder has reached a point where it can no longer be regarded as a reproach to the profession. Clinical Forms of Rheumatism. It is necessarv to divide Rheumatism. ill rheumatic cases into but two classes for therapeutic purposes, acute and chronic. If the acute stage is properly and thoroughly managed there will very rarely indeed be any chronic stage to consider, but this could not have been affirmed before the therapeutical ad- vent of dry hot air. The cause of chronicity has resided mostly in impairment of local and general metabolism, through the influence of long-continued pain and the long-continued pres- ence of rheumatic toxins in the blood and tissues of the affected regions, by reason of which it became impossible for the remedies ingested to be assimilated effectively by such tissues. Dry hot air, through its power of relieving stasis and stimulating sluggish metabolism, renders rapid and effective the assimilation of the appropriate remedies, the general ner- vous system is not therefore subjected to drug pain or un- endurable toxin depression and recovery is rapid and satis- factory. It is probably not practicable to drop the term " chronic " rheumatism entirely at present because inefficient medication or conditions of general debility present when the infection was contracted, or which supervene because of a protracted attack, will combine to cause chronicity; as previously sug- gested, however, great care should be exercised in making a diagnosis of chronic rheumatism. Complications. It is hardly necessary to state that any other pathological conditions which may exist when an attack of rheumatism is sustained should receive attention. Some- times the system is so depressed by such a complication that the rheumatism cannot be removed until such complication has been attended to. We once had a patient under treatment for rheumatic polyarthritis for three weeks and were able to se- cure only temporary relief. At last it was discovered that she had a tapeworm, a fact of which she had previously had no suspicion. After the removal of an eighteen-foot parasite her recovery was immediate and perfect. Local Dry Hot Air Application. The local treatment is usually the only thermo-therapeutical modality which it is necessary to employ in the treatment of true rheumatism. If 1 1 2 Therapeutics of Dry Hot A ir. more than one joint are affected as many as possible of them should be treated at once with as many separate apparatuses. It should be applied at least twice a day at a temperature of from 350 to 400 F. for an hour until the soreness and pain in the parts have entirely disappeared. When the pain returns after the treatment the same may be applied again immediately. Usually fifteen or twenty minutes will entirely remove the pain from the most violent cases, and it remains quiescent for a variable period, ordinarily from four to six hours. By re- peating the application whenever the pain returns the patient can be kept practically free from marked discomfort during the whole of his convalescence, the inauguration of which usually coincides with his first dry hot air treatment. After-Care. Suppression of the functions of affected joints after the thermal application is always helpful, but not always absolutely necessary. Massage and passive movement are always unnecessary and sometimes interfere markedly with the patient's comfort, either immediately or shortly afterwards. The limb may be done up in absorbent cotton or flannel, but liniments or other external applications are usually uncalled for and useless. General Dry Hot Air Application. The body dry hot air treatment is always useful and occasionally necessary for removing metabolic impairment from systemic toxaemia and debility, but for the routine treatment of the disease it is not essential. An important advantage contingent upon the employment of dry hot air applications in rheumatism is that as local metab- olism is thereby kept at its point of greatest activity, assimi- lation of medicines by the tissues of the infected regions is rapid and complete; less of the drug is therefore required to be in- troduced into the general circulation and less systemic dis- turbance ensues therefrom. As a matter of fact, when dry hot air is administered in conjunction with the proper salicyl com- pound systemic disturbance of any sort or degree is of ex- tremely rare occurrence. R/teu ma tism. 113 Additional Remedial Measures. Diet. Rigid restriction of the diet within narrow limits in this disease is not of nearly as much importance as is ordi- narily supposed. Its regulation should be governed by the manifest needs of the patient's economy and the effects of the unaccustomed conditions surrounding him as regards lack of exercise, etc., rather than by the mere fact that he has rheu- matism. The disease has in the past been so inextricably en- tangled with lithaemic and gouty conditions that the diet has been made to assume an unduly specific character. The patient should be fed as would a person sick with any other disease which had impaired his power of digestion and assimilation, and whose muscular and nervous systems were weakened by toxaemia and sluggish from lack of exercise. If his digestive powers are equal to beefsteak it may be given him without fear. Plenty of liquid in the form of milk (one quart per day) or water (carbonated, plain, or in lemonade) is essential for the patient's best good. Drugs. From what has been said in previous sections it will be seen that salicylic acid in some form should always constitute one of the principal elements of anti-rheumatic therapy. Because of its irritative tendencies toward the stomach and kidneys and its depressing influence upon the heart, however, it some- times so impairs digestion, assimilation, and metabolism either general or local, or both, that it destroys its own effectiveness by rendering impossible its ingestion in sufficient quantity ; hence the selection of the particular form in which it is to be administered is important. Those most worthy of consideration are aspirin, salicin, sodium salicylate. salophen, and methyl salicylate, and their desirability according to our experience is in the order in which they are named. Aspirin. This drug in doses of 3 or 4 grams per day is usually a perfectly effective anti-rheumatic and very rarely indeed produces any irritation of the stomach or kidneys or depression of the heart. Occasionally slight tinnitus or heart- 1 14 Tkerapfiftics of Dry Hot Air. burn follows its use, and rarely a patient is encountered who cannot take it at all. Salicin. The bitter principle of willow bark is nearly as effective, but must be given in much larger quantities (4 to 10 grams daily), and the bulk is objectionable. Salicin has the advantage over all the others of being an excellent stomachic, and constitutes a most useful succedaneum to sodium salicylate when the latter drug has impaired digestion; it serves admi- rably to remove the gastric debility as well as to keep up the salicyl saturation of the blood. Sodium Salicylate. The gastric and renal consequences of administering this substance in full doses need only to be mentioned in order to be appreciated, but in cases where it is tolerated no drug performs better service. Salophen. A very useful drug which may be safely given in gram doses three times daily and does good analgetic work for a day or two, but in order to get a marked and sustained curative action larger quantities are usually required and then the heart is apt to suffer. It is, however, extremely valuable in some cases, and I shall refer to it again in con- nection with sciatica. Methyl Salicylate. This preparation is sometimes given by the mouth, but our experience has been that its use should preferably be restricted to external application after dry hot air treatments with those patients who cannot take any of the others in sufficient doses per os. Three or four thicknesses of gauze are laid smoothly over the joint affected, 5 or 10 grams of methyl salicylate soaked into it, and gutta-percha tissue wrapped around the whole and retained in place by a roller bandage. It enters the circulation by absorption through the skin. Alkalies. The practice of administering alkalies in this affection with or without a salicyl compound is a common one, but modern conceptions of the pathology of the disease do not furnish a logical indication for it, and although it does no harm, I have never been able to convince myself that it did any good, and have abandoned it It will not frequently be found necessary to go beyond Rheumatism. 115 aspirin. This drug is not miscible with water, but by thor- oughly incorporating it with an equal quantity of powdered sugar it may be suspended in the liquid, and is best given in this manner, or in konseals. In chronic cases, where pain is not a factor demanding immediate attention, it is well to precede the first dry hot air treatment by two or three doses of the salicyl selected. We thus secure a preparatory saturation of the patient's system and the case seems to progress more rapidly thereafter. In acute cases, however, immediate relief of the constant harass- ing pain is imperative, and the thermal application should be employed at once. Salines. As in every other general infection, the bowels must be kept freely open, and salines are the best agents to employ for this purpose. Electricity. The electrical currents usually play but a secondary part in the treatment of rheumatism when dry hot air is available. When dry hot air is not at hand, however, and sometimes in combination with dry hot air they are extremely useful and may be applied as follows : The Static Current. The spray over the spine for its general tonic effect, and the brush discharge for from thirty to forty minutes over the seat of the inflammatory process for sedation, relief of swelling, and improvement of metabolism. Sometimes the Morton wave current is extremely helpful in this situation. The Magnetic-Induced Current. Rapidly interrupted cur- rent from long, fine-wire coil passed directly through the tissues affected, for sedation and improvement of metabolism. The Voltaic Current. The positive pole over the affected tissues in acute cases, current uninterrupted will frequently give temporary relief from the pain and should be tried first, but sometimes the polarities must be reversed to obtain this result. We can tell which only by trying. Occasionally a case is encountered wherein a muscle remains sore upon movement after the attack has apparently entirely ended, and here a few 1 16 Therapeutics of Dry Hot Air. applications of the negative pole of the slowly interrupted galvanic current to the complaining structure will usually dis- sipate the trouble. In addition to its sedative action the galvanic current exercises a curative influence upon the disease through its power of stimulating tissue metabolism. Its action in this direction is probably identical with that of dry hot air, but much less powerful. When the part affected is a hand, foot, wrist, or ankle, the use of a hot-water bath electrode in which the member can be immersed is much more effective. From 5 to 15 milliamperes may be used for from ten to fifteen minutes. Franklinism is the most useful of the electric modalities in rheumatism. CHRONIC RHEUMATISM. This term is used less and less frequently as our diagnostic knowledge and ability increase. Treatment. The management differs in no essential par- ticular from that of the acute form except that as a considerable degree of general debility is nearly always present, the body treatment assumes a position of some importance in its man- agement. It may be administered two or three times a week. Because of this general debility other tonic measures such as static sparks, the wave current, galvanism, mechanical vibra- tory stimulation, etc., are most helpful. When dry hot air is not available these agents will render good service. The drug treatment differs in only one particular from that of the acute form, viz. : the addition of general tonics to the salicyl regimen. CHAPTER VI. LOCAL SEPTIC INFECTION. Modifications of Clinical Conditions producible zvith Dry Hot Air. Local Application. First, rapid relief of pain if applied before suppuration has become established, and partial relief if this event has already supervened. If confined pus is present the pain is sometimes increased. Second, abrupt arrest of the tendency of the disease to pro- gressively involve structure after structure, and sharp localisa- tion of the process and products of inflammation. General Application. First, a marked stimulation of the vital functions indicated by improvement in the circulatory phenomena before the patient leaves the apparatus, which is not followed by any per- nicious reaction. Second, rapid relief of the nerve centers from a large degree of toxin depression, because of the increase effected in the] process of elimination. Third, abrupt arrest of the tendency of the process to involve other structures, because of the augmented physiological re- sistance of the threatened tissues due to the vital stimulation* and elimination effected. Fourth, avoidance of evil reaction from drug stimulation, because an amount of depression sufficient to demand the em- ployment of such remedies does not ordinarily obtain after the administration of body treatments has been commenced. One of the most dreaded of the pathological states encoun- tered with a moderate degree of frequency to-day is septic infection. In spite of the most careful observance of the 1 1 8 Therapeutics of Dry Hot A ir. elaborate aseptic and antiseptic technique which has been de- veloped from the never-to-be-forgotten work of Sir Joseph Lister, pathogenic micro-organisms will sometimes gain a lodgment in operation wounds, bringing in their train the usual accompaniment of harassing anxiety, protracted illness, suffering, and sometimes death; cuts and crushing injuries are frequently infected at the time they are sustained, or neglected then and infected later. Prevention is, of course, the best treatment, but in many cases prevention fails and in others it is impossible of attainment, so that some effective agent for combating established septic infection will always be in demand. Dry hot air satisfies this demand in a gratifying manner. RATIONALE OF THERMOTHERAPY. Etiology and Pathology. In order to comprehend fully the logic of the application of the agent to this disease let us glance for a moment at the pathological conditions obtaining and which it is the aim of treatment to overcome. The primary etiological factor consists of the lodgment in the lymph spaces of pathogenic micro-organisms. After this event has occurred, one of two things will happen: First, what we will denominate the patient's constitutional resistive power, may be intense enough to enable the cells composing the invaded tissue to destroy the infective organ- isms, in which case nothing further will be heard from them. Second, the patient's normal constitutional vitality may be lowered from some cause, or the resisting power of the tissues attacked may be weakened, as by impairment of the trophic nervous control from injury or shock, for instance, in which contingency the invading organisms find a pabulum suitable for their development. Once established they multiply with exceeding rapidity, spreading colony after colony into the numerous ramifications of the lymphatic system, until finally millions of bacteria are vomiting toxins upon the contiguous tissue cells, paralyzing their vitality and rendering larger and larger areas of tissue a favorable soil for further germ propa- gation. These toxines, together with the ptomaines resulting Local Septic Infection. \ 19 from abnormal tissue metamorphosis, are taken up by the general blood circulation and brought into contact with all the nerve centers and other tissues of the body, exercising there- upon a most viciously depressing influence, whence results the evil clinical picture so harassingly familiar to most of us as " blood poisoning." Two important points to be borne in mind in this connection are, first, that when the normal resisting power of the tissues is unimpaired it is probable that they are capable of resisting any ordinary microbic invasion ; second, that most of the com- mon pathogenic germs require for their propagation that the conditions most favorable to their development as regards the temperature of their environment, etc., be maintained with a moderate degree of uniformity. Therapeutic Indications. The objects of treatment as deduced from the above, then, would be as follow: First, so to modify the environment of the colonies of micro- organisms as to accomplish their destruction, inhibit their development, or lessen the virulence of their toxic ema- nations. Second, to increase the physiological resistance of the in- fected organism as a whole, and of the cells composing its tissues as individuals. Third, to eliminate as rapidly and profusely as possible the toxins already in the circulation. The local and general applications have their distinct spheres of action in this disease, and it will assist in the elucidation of the problem before us if we consider them separately, bearing in mind their physiological actions as described in Chapter II. Local Application. When a local dry hot air application is made to one of the extremities of the body exhibiting the evidences of septic infection, the following sequence of events is inaugurated thereby. First, the reflex stimulation of the vasomotor tracts through thermic irritation of the nerve endings in the skin relieves the fluid stasis in the part, thereby lessening the pain. Second, the nutrition and cell vitality of the part are aug- 1 20 Therapeutics of Dry Hot A ir. mented by reflex stimulation of the trophic nerve supply through the same influence. Third, the raising of the temperature of the part en masse disturbs one of the most important conditions, which it is essential should be maintained unimpaired if the propagation of the micro-organisms is to reach its fullest development. Fourth, the integumental emunctories are stimulated to greatly increased functionation. Resulting from this we find that, first, the lessening of the pain quiets the patient's nervous system in direct proportion as the relief is complete, thereby conserving his nervous energy, and the relief of stasis insures a plentiful supply of raw material in the form of an augmented blood circulation, out of which new cells may be built up to take the place of the debilitated, toxin-impaired elements. Second, the augmented trophic impulses result in advantage being taken of this increased supply of raw material for the rapid formation of cells possessing a heightened vitality, whereby the resisting power of the tissue is at once greatly increased. Third, the raising of the temperature of the part en masse probably exercises an inhibitory influence upon the develop- ment of the colonies of micro-organisms, whereby the virulence and quantity of the toxins emanating therefrom are reduced in direct proportion as the inhibition is profound. Fourth, the enormously increased functionation of the sweat glands removes directly from the parts most profoundly influ- enced by the intoxication, a certain proportion of the noxious substances which had previously been devitalizing fresh areas of tissue and passing into the general circulation. As a consequence, instead of the destructive process spread- ing farther and farther into the sound tissues, we find that the cells at the periphery of the infection, which were just be- ginning to feel the debilitating influences of the approaching destruction, are regenerated and carry on their metabolic and reconstructive functions with a normal, or perhaps even an increased, degree of activity, pushing the lines of healthy tissues farther and farther into the diseased areas, until Local Septic Infection. 1 2 1 finally the pathological mass is entirely replaced by healthy tissue and the patient has recovered, frequently without even a slough. When a collection of pus is present before treatment is begun, however, it is necessary that it be evacuated, neither dry hot air or any other measure with which I am acquainted being capable of producing absorption. When pus is so present this agent exhibits another valuable attribute, viz., the power to localize the inflammatory process very closely to the abscess cavity when a stroke of the knife will end the trouble at once and forever. General Application. When the lymphatics of the joint connecting the invaded limb with the trunk have become in- fected, or when severe general toxaemia is present, the physio- logical effect of the local treatment will not usually be sufficient to produce a cure, because in these cases foci of infection are located in parts so situated that the maximum influence of the local treatment cannot be brought to bear directly upon them. Under these conditions it becomes necessary to call up all of our patient's reserve forces, to stir his vital resistance against the invading organisms to its profoundest depths, and the general application is indicated. With this measure we cannot invoke the directly inhibitive influence upon germ development due to the raising of the temperature of the part that is obtainable with the local treat- ment, because the mouth temperature is rarely increased by the body treatment beyond 3 F. above the normal, and this is not enough to appreciably retard the growth of the streptococcus ; indeed, patients very frequently exhibit elevation of tempera- ture to this extent and more when they enter the apparatus. The greater beneficial power of the body treatment consists in, first, the greater proportion of systemic toxaemia which is eliminated through the resultant increased functionation of the skin, kidneys, and lungs, whereby the vital processes are more efficiently relieved of impairment and depression ; and, second, its gratifying influence in stimulating to renewed vigor of function the deep spinal and sympathetic nerve centers that control tissue reconstruction and general metabolism, and which 122 Therapeutics of Dry Hot Air. have been overwhelmed to a greater or less extent by toxin accumulation in the general circulation. By its use is secured an increased activity in the resistance to further invasion on the part of the threatened tissues, and at the same time a more rapid elimination of the noxious products of such invasion as has already taken place. The hyperleucocytosis which results from the body dry hot air application has been looked upon as an important element in the production of its beneficent effects in this disease. Whether this phenomenon, per se, has anything to do with the case, however, cannot be determined until the exact role of hyperleucocytosis in infectious processes is ascertained, and that is a matter for the future to decide. It has been stated that local dry hot air applications will always increase the pain attending a localized septic process if pus is present, and that it is, therefore, of value as a diag- nostic test for detecting the presence of suppuration. The writer has repeatedly seen the pain attending localized pus collections markedly relieved by local dry hot air applications, and has, therefore, no hesitation in expressing his absolute lack of confidence in this measure as a differential diagnostic test. ILLUSTRATIVE CASES. With regard to their treatment by this agent, cases of septic infection may be conveniently divided into three classes, as follow : First, those in which the infection has taken place in a limb, and has not yet invaded the lymphatics of the joint connecting the member with the trunk, and which are nearly always early cases. Second, those in which the lymphatics of the joint connecting the infected limb with the trunk have also become involved, but where the original focus of infection or other tissues have not yet become so profoundly affected as to demand surgical removal. Third, those in which the lymphatics of the trunk are in- volved and tissues or glands are so hopelessly diseased as to demand immediate operative ablation. Local Septic Infection. 123 The following reports have been selected with a view to illus- trating these types ; Case I exemplifies the first class. Case I. The writer's first experience with dry hot air in the treat- ment of well-marked septic infection, was on September n, 1900. A patient was admitted to the sanitarium on that date who had developed a septic process from a cut on the little finger of her left hand two days previously. She had suffered intense pain for thirty-six hours, temperature had reached 103.5 F., pulse 112, and marked prostration was present. The hand and wrist had become involved, and red streaks followed the lymphatics up the arm nearly to the elbow. A local dry hot air treatment was administered in the hope of relieving pain, which it accomplished in forty-five minutes, and the patient slept for the first time in twenty-four hours. That evening, to my intense surprise and gratification, the patient's temperature had dropped to 99.2 F., the pulse to 60, and the pain had not returned to any great degree. By the next morning the swelling and redness had nearly dis- appeared, but the temperature had risen again to 101.4 F., the pulse to 84, and the pain was considerable again. She was given a body dry hot air treatment. The pain in the affected hand and arm was relieved during this procedure, and did not return again sufficiently to demand another local treatment, and, to make a long story short, the affected members pro- gressed to a complete and fairly steady recovery during the next four days,' at which time the temperature reached the normal point and stayed there. The next two cases were reported by me in the Medical News, issue of July n, 1903, and illustrate the second and third types of infection, respectively. Case II. Mr. G. P. H., thirty-two years old, was brought to the sani- tarium March 2, 1901, by Dr. A. S. Cheney, of New Haven. Four days previously he had cut his hand with a dirty jack- knife. The usual evidences of infection duly appeared, and when he entered he was in a condition of profound prostration, with a temperature of 103.4 F., respiration 28, but the pulse was only 86. Hand and arm were considerably swollen. Lym- phatic glands about the elbow and in the axilla were irregularly enlarged, those in the latter situation to about the size appar- ently of an English walnut. He was in constant, severe pain. The presence of deeply-located suppuration seemed probable, 1 24 Therapeutics of Dry Hot A ir. but was not positively demonstrable. He had been brought in with the intention of operating the next day. It was finally de- cided, however, to treat him with dry hot air first, holding operative interference in reserve. At noon of the day following his admission he was given a body dry hot air treatment at 340 F. Perspiration was pro- fuse, the pain was relieved entirely before the conclusion of the treatment, and he had a quiet, refreshing sleep after he had been removed to his bed. The evening temperature was 102.5 F., as against 103.4 F. on the previous day. Next morning, at eight o'clock, his temperature was 99.9 F., pulse 84. The patient had slept several hours during the night. The pain had not returned to any great degree, and the prostra- tion and nervous symptoms were greatly lessened. The swell- ing in the hand and arm were less, as was also the enlargement of the glands in the axilla. He was given another body treat- ment at noon at 350 F. His temperature was 101.8 F., pulse 80, as against 102.5 F. and 94 respectively the preceding evening. Treatment was administered again late in the afternoon. Morning temperature the next day was 99 F., pulse 78. Patient had slept at intervals during the night and during the day, resting quietly. That evening his temperature was 100.4 F., pulse 76. Pain and swelling had entirely gone out of the arm, but the axillary enlargement persisted, as did also a con- siderable amount of pain in this region. The following day, March 7, his morning temperature was 99.4 F., pulse 76. In the afternoon he was given a body dry hot air treatment at 350 F., and the next day his temperature in the morning was 99 F., pulse 70. In the evening the tem- perature rose to 100.6 F., with the pulse averaging 88. At this time palpation of the axillary enlargement demon- strated the presence of pus, and it was decided to open the axilla the next day, which was done at four o'clock in the afternoon, Dr. Cheney operating. Upon incision, a large quan- tity of fluid pus was evacuated and a pocket was discovered running up under the clavicle for a distance of about three inches, of a diameter sufficient to admit of exploration with the forefinger, but no glands outside of it were involved in the infective process. It will be observed that this is a very differ- ent picture from that usually encountered under these condi- tions, where the contents of the abscess cavity consist of pus with a plentiful admixture of cheesy detritus, which it is not at all easy to remove in a thorough manner, and where gland after gland is found to be infected, necessitating a vast amount of dissection, in order that the extirpation shall be complete. Local Septic Infection, 125 The abscess cavity was curetted out and the subsequent progress of the case towards recovery was rapid, satisfactory, and uneventful. On March 13 the body temperature returned permanently to the normal point, and he was discharged on March 23, just three weeks after his admission, entirely re- covered from an attack of septic infection which was very evidently seriously threatening his life when he entered. This case illustrates the necessity of combining operative interference with dry hot air treatments in those cases where such structures as lymphatic glands have become diseased to such an extent that disintegration is inevitable, or when pus accumulations are present. The immediate improvement in the patient's general condition after the first dry hot air treat- ment, together with the strenuous localization of the inflam- matory process in the axilla, illustrate respectively the happy influence of this measure in lessening general systemic tox- aemia, and in preventing the spread of the infection from struc- ture to structure, through its power of increasing the physio- logical resistance of the cells composing the threatened areas. Case HI. Mr. A. W. A., aged fifty-one years, was admitted to the New York Hospital on the morning of January 8, 1902, with a traumatic amputation of the left foot at the ankle, sustained in a railroad accident. The crushed member was attached to the leg merely by the lacerated posterior tendons, and the patient, of course, was suffering considerably from shock. Amputation of the lower third of the leg was done by Dr. Francis Marcoe that afternoon. Septic infection, however, de- clared itself three days after the injury. On January 12 it was noticed that the knee was swollen; on January 15 pus began to discharge from the wound, and in spite of the utmost care the condition increased until January 23, fifteen days after the original injury. At this time the leg up to the knee, and some- what above this joint, was enormously swollen, the tissues of the stump were sloughing in places, and the patient's general condition was one of extreme prostration. In short, he pre- sented a typical picture of the severest form of blood-poisoning, except that streptococci had not been found in his blood. It was decided to amputate the infected member above the knee as a forlorn hope. This was done by Dr. Frank Hartley on the evening of January 23, at the middle of the thigh. 1 26 Therapeutics of Dry Hot A ir. Patient rallied very well from the operation, and the next morning was given a body dry hot air treatment. During the time intervening between January 24, the day of the second operation and March 8, the day of his discharge from the hospital, the patient received thirteen body treatments, the greater number of which, of course, were given during the two weeks immediately succeeding the amputation of the thigh. His general condition began to show slight evidences of benefit at once in the way of increased comfort, ability to sleep, and improvement in the vital signs, and he continued to gain slowly but steadily until by February 5 his improvement had become so manifest as to justify a prognosis of recovery with a moderate degree of certainty. From this date on his improvement was entirely satisfactory ; to-day his general con- dition is better than it has ever been in his life before, and he weighs more without his leg than he ever did with it. In order to indicate the gravity of the case, I will say here that it was the unanimous opinion of the physicians who saw him that neither the operation or any other ordinary therapeu- tical measure would save the patient's life. The fact, also, that slight evidences of tissue disintegration appeared in the wound three days after the second operation, is indicative of the fact that the operation and therapeutical measures other than dry hot air would not have sufficed to secure a successful termina- tion. As far as I know, this agent has never been called upon to influence a case of septic infection in which streptococci were present in the general blood circulation, or a case of puerperal sepsis, but its physiological action, and what is known already of its clinical possibilities, indicate that it would be of assist- ance in even these ordinarily desperate conditions. TREATMENT. Local Dry Hot Air Application. With cases belonging in the first-mentioned category, local treatment of the affected limb is usually sufficient to effect a cure. The technique does not differ from that usual to the local treatment, and the tem- perature should be run up to 300 or 400 F., according to the tolerance of the patient. In cases of the second and third classes, the local treatment Local Septic Infection. 1 27 is rarely indicated except to relieve pain or to hasten sluggish healing processes, because, as before stated, the menacing lesions are too deeply located to render possible its effective application. General Dry Hot Air Application. This measure is not called for in cases of the first class, unless considerable general toxaemia is present, but in cases of the second and third classes it is the remedy par excellence. The technique is that usual to this treatment, except that we cannot use the temperature of the patient as a guide to the duration and intensity of the application, because it is usually considerably elevated when the patient is placed in the appa- ratus. The pulse also is not entirely reliable as a guide. We have to be governed more by the effect upon the organism as a whole, and the instinct which is the result of experience is most valuable in this connection. In general, however, it may be said that the treatment should last not less than twenty minutes, and that the temperature required will vary from 250 F. to 350 F. The response on the part of each individual patient at each seance will govern both intensity of the heat and duration of the application. As a rule, it will not be wise to push the pulse above 140 beats per minute, and the symptoms noted under " Technique of the Body Treatment," as indicating excessive stimulation, should be carefully avoided. Usually the first indication that the toxaemia is diminishing is a lessening of the nervous erythism, which becomes manifest immediately after, and sometimes before the conclusion of the first treatment, when the patient frequently falls into a refresh- ing sleep lasting from one to several hours. The augmented functional vigor of the deep spinal sympa- thetic nerve centers is evidenced before the patient leaves the apparatus by the improved character of the pulse, within four or five hours by a fall in the body temperature, and within twenty-four hours usually, the re-invigoration of the trophic functions is manifested by a marked lessening or a sharp locali- zation of the local inflammatory phenomena. A point deserving of consideration when treating these cases is that when a patient has been severely septic for several 128 Therapeutics of Dry Hot Air. days, as many have been before they are given the benefit of dry hot air, his nervous system exhibits the irritability of depression to a marked degree, and he is not able to endure the body treatment for half an hour. Under these circumstances the heat should he run up quickly, for instance to 300 F. in fifteen minutes. By this means a quick and effective stimula- tion may be induced before the patient's endurance is exhausted, whereas, if the temperature ran up as slowly as would ordi- narily be the case, it would not be possible to secure the neces- sary deep reflex response without forcing the length of treat- ment beyond a judicious limit. Additional Remedial Measures. Diet. The management of the ingesta does not differ in any particular from that ordinarily indicated in this condition. Drugs. Medicines are useful to keep the bowels open and to correct digestive derangements ; magnesium sulphate for the former and digestive ferments, with small doses of strychnia for the latter. It is, however, very rarely indeed necessary to give them to relieve pain or for stimulation, after the adminis- tration of dry hot air is begun. Operative Interference. The aid of surgical measures should be promptly enlisted whenever glands or other struc- tures have become diseased beyond the possibility of repair, or so that their further preservation involves serious menace to the patient, and when suppuration has become established. Dry hot air will not remove moribund tissues or pus. Its great func- tions in suppurative cases are to relieve pain, prevent the in- fection from spreading to contiguous structures, lessen the sys- temic toxaemia, and hasten repair of damaged structures, and these it accomplishes nobly and well. It is not necessary to protect operation wounds during dry hot air applications with more wrappings than the rest of the body, and the proper surgical dressings will ordinarily be sufficient. The healing of such wounds is hastened by the treatments. Electricity. Electricity never enters the therapeutical prob- lem when dry hot air is available, except to assist in healing Local Septic Infection. 129 sluggish sinuses. Here the negative pole of the galvanic battery, applied to the offending granulations through a bare metal electrode, using from three to five milliamperes of cur- rent for five or ten minutes, will do more execution than any other measure with which I am familiar. Care should be taken not to use enough current to cauterize ; the good results are effected by electrolysis, not by destruction. CHAPTER VII. PNEUMONIA. Modifications of Clinical Conditions producible with Dry Hot Air. Local Application. First, immediate relief of pleuritic pain lasting for from one to eight hours, which is conducive to the patient's comfort, hence conservative of his vital energy. Second, relief of that proportion of the cough and respira- tory embarrassment due to the pleurisy. Third, a marked inhibitive influence exerted upon the growth of the pneumococcus colonies in the area of consolidation whereby the circulation and nerve centers are relieved from a large proportion of the toxin depression and irritation which result from their unimpeded development, and a decrease of febrile movement of from half a degree to one degree Fahren- heit is usually secured within twelve hours. Fourth, rapid absorption of the exudate to such an extent that the physical signs of consolidation entirely disappear in from one to four days after the first application, which dimin- ishes the danger of cardiac distention and removes the symp- toms caused by encroachment upon functionable respiratory areas. General Application. First, a reflex stimulation of the vital powers unparalleled in extent and profundity by that producible with any other measure, and which is evidenced by marked improvement in the circulatory function before the patient leaves the apparatus. Second, relief of the pulmonary blood-vessels by a dilatation of the peripheral circulation, the extent of which again is un- surpassed, if not unequaled, by that obtainable with any other measure now known. 130 Pneumonia. J 3 l Third, elimination of toxins already formed and in the blood, to an extent and with a rapidity unattainable by any other means. Fourth, reduction of excessive body temperature amounting to from half a degree to a degree and a half Fahrenheit, and marked improvement in the general symptomatic phenomena, within five hours after administration. The writer was first led to use this agent in pneumonia by his observation of its kindly influence upon a case of peritonitis, and the first case of pneumonia so treated was reported in the New York Medical Journal for October 2, 1899. The agent was applied to this case more in the hope of relieving the pleuritic pain than of influencing the pneumonic process, but to the writer's surprise and gratification the general and local pneumonic symptoms were mitigated as well as the pleurisy, and in subsequent cases it has confirmed its claims to respect then put forward as a therapeutical measure with which to attack this infection. At the present time the writer believes that judiciously and thoroughly (I desire to emphasize these two adjectives) applied dry hot air treatments constitute one of the most efficient means now known for combating this disease. RATIONALE OF THERMOTHERAPY. A brief consideration of the etiology and pathology of the disease is necessary in order that the rationale of its power to produce these results may be comprehended, and the con- ception of the same put forward by Dr. Andrew H. Smith, of New York, N. Y., carries with it more conviction than any other of which I am cognizant. In addition, it offers plausible explanation of the action of dry hot air in this disease. Briefly, Professor Smith's explanation is as follows: Etiology and Pathology. The primary etiological element consists of the development of cultures of pneumococci in the pulmonary alveoli, from which toxins are absorbed into the circulation, and produce the general systemic disturbance, in- cluding " heart failure." The pabulum for the growth of the micro-organisms is constituted by the fibrinous exudate which 132 Therapeutics of. Dry Hot Air. pours into the alveoli because of the irritation of their walls by the presence of the germ colonies. That it is not an inflammation of the lung tissue in the ordinary sense is indicated by the fact that any such inflam- matory process of a sufficient intensity to produce the clinical phenomena of pneumonia would very surely be followed by irreparable destruction of large masses of pulmonary tissue, whereas, in this disease after the process has subsided, the in- tegrity of the lung structure is usually entirely restored; and that autopsical findings demonstrate that the bronchial or nutrient circulation is very rarely involved at all, but that when it is, gangrene of the areas strangulated is very sure to result. This means that obstruction of the pulmonary or functional circulation by the exudate, and reflex pneumogastric irritation due to the same cause, are probably responsible for the greater part of the respiratory, and much of the cardiac disturbance ob- served in uncomplicated pneumonia. The life of the pneumococcus in artificial cultures is from ten to twelve days, and it is one of the most sensitive of all bacteria to changes in the conditions of its pabulum as regards tempera- ture, reaction, etc. It grows best in faintly alkaline media, and a marked acidity will entirely inhibit its development, hence the fibrinous exudate in the air-cells constitutes an ideal cul- ture medium. During the process of hepatization pneumic acid forms, and when the saturation of the exudate reaches a sufficiently high point, the further development of new colonies of germs is thereby inhibited. It is by reason of this fact, together with the exhaustion of the culture medium (exuded fibrin), and the possible formation at a certain stage of an antitoxin, that the termination by crisis obtains. Modifications of these conditions produce termination by lysis. Professor Smith presented the subject in detail in an address to the New York Academy of Medicine, which was published in the Medical News for December 18, 1899. During the course of this address he states his " views as to the sequence of events taking place in an attack of pneumonia," to be as follow : Pneumonia. 133 " i. The occurrence of some cause of depression, either local or general, which favors the germination of pneumococci, al- ready present in some one of the smaller tubes. " 2. The formation of a colony that spreads until it reaches the group of air-vessels that are terminal to the tube in ques- tion. " 3. The setting up of an irritation in these vessels, causing a fibrinous exudation, an emigration of leucocytes, and a diapedesis of red cells from the functional capillaries. " 4. The formation of a colony of pneumococci in the medium afforded by this exudate. " 5. Arrest of the blood stream in the functional capillaries, followed by accumulation of free pneumic acid in the paren- chyma of the affected area. " 6. Overflow of exudate into neighboring lobules, starting the process in them also. " 7. Arrest of germ growth by the exhaustion of the medium and the accumulation of free acid in the tissue of the lung. Up to this time there has been a constant formation and ab- sorption of toxin. " 8. Retrogressive changes in the exudate preparatory to its removal by absorption. " 9. Probably, in this latter process, formation of an anti- toxin principle. " 10. Entire removal of the exudate, and restoration of the vesicle to its normal condition. " ii. Resumption of the functional capillary circulation." The points to be borne in mind in considering this part of our subject, then, are as follow : First, the diplococcus of Frankel is an organism exquisitely sensitive to changes in the temperature and character of its pabulum, and its life period in laboratory cultures is from ten to twelve days. Second, we have a condition here which is closely analogous to that which obtains when cultures of the organism are grown in the laboratory ; the walls of the pulmonary alveoli acting as test-tubes and the exuded fibrin as culture medium, to appro- priate another of Professor Smith's apt expressions. 1 34 Therapeutics of Dry Hot A ir, Third, when consolidation has taken place, the layers of the pleurae being in apposition, and even sometimes absolutely ad- herent, from fibrin exudation, we have practically a solid tissue from the integument to the inner limit of the consolidation, ex- cept in those comparatively infrequent cases where the con- solidation is central exclusively. Fourth, the general systemic phenomena, including " heart- failure," are due to the influence upon nerve centers, muscles, and glandular structures, of toxins emanating from the germ cultures in the alveoli and absorbed into the blood. Fifth, the most virulent toxins are produced where the colonies are youngest, hence come from the periphery of the affected area where the cultures are thinnest and spreading into other alveoli. Sixth, in many cases, much of the cough and a considerable proportion of the respiratory acceleration, are due to reflex irritation and pain, set up by the pleurisy which usually accom- panies the trouble. A bit of clinical evidence in favor of this probability is that local dry hot air applications do not immedi- ately diminish the respiratory acceleration or cough much, unless pleurisy is present. Seventh, death is directly due either to paralysis of nerve centers from toxin absorption, or paralysis of the right heart from over-distention of the ptomaine-impaired viscus precipi- tated by massive exudate. Therapeutic Indications. The objects of treatment may be briefly stated as follow : First, to secure the destruction of the colonies of pneu- mococci in the lung, or, failing this, as profound an inhibition of their development as possible, whereby the quantity or virulence of toxins introduced into the general circulation would be diminished. Second, to secure as rapid and profuse an elimination of the toxins already in the body as possible. Third, to secure absorption of the exudate as rapidly as possible. Fourth, to relieve pleuritic pain when present. Fifth, to increase the patient's vitality and metabolic ac- Pneumonia. 135 tivity, whereby his physiological resistance and recuperative capacity will be augmented. Local Application. Now, when a local dry hot air treat- ment is administered over a consolidated lobe, it is reasonable to infer that the heat could be made to penetrate in some degree nearly, if not quite, through the whole of the affected area by conduction, as the part is then practically a solid tissue, and the heat is applied to the front and back, as well as the side of the chest over the affected region. If this is true, then the temperature of the pabulum of the invading micro-organisms could be raised, and one of the most essential conditions of their well-being disturbed. We have seen that it is only in the absence of a disturbance of these conditions that this germ is able to grow at all, hence this result would very certainly exercise an inhibitory influence upon its development, from which would result a lessening of the quantity and virulence of the toxins formed. As the general symptomatic phenomena are due to absorp- tion of these same toxins, any influence which lessened their quantity or virulence would also lessen the intensity of the general symptoms, and we should expect, as a result of the application of such an influence, a drop in the body temperature and a considerable amelioration of the depression of the nerve centers ; and bedside experience proves this deduction to be true. But the question at once arises, " If this is true why would it not be possible to abort pneumonia, to cut the attack short at once with the local dry hot air treatment ? " We have seen that the germ c'olonies tend to invade other air-cells and bronchioles by spreading from the periphery of the consolidated area, and that these youngest, peripheral colonies give rise to the most virulent of the toxins. Those air cells and bronchioles, which have been newly invaded, are not yet consolidated, hence have not yet become solid tissue, and air circulates through them. It would, therefore, be im- possible to raise the temperature of these parts very markedly if at all, and the inhibitory influence susceptible of induction in the fully consolidated portion could not be attained here. 1 36 Therapeutics of Dry Hot A ir. These colonies, therefore, would continue to multiply and spread until they had reached the end of their normal life period, and the system at large would continue to feel the effects of such toxins as emanated from these areas, although relieved from those formed in the original and larger focus. As a consequence, we should expect some fever, acceleration of pulse and respiration, general prostration, etc., to continue until the natural period for the termination of the attack had arrived, and this is exactly what happens. The patient, being relieved from a large degree of the intoxication from the greater bulk of the infective focus, exhibits a marked and im- mediate improvement, but does not recover entirely until the infection has reached the period of its normal defervescence. Further, in this connection, it would be expected that, if the dry hot air applications were discontinued too soon, the germ colonies at the periphery of the original focus of infection would again multiply, so as to produce some amount of consoli- dation and an increase in the systemic disturbance. Bedside experience also confirms this expectation. A final logical inference would be that central pneumonia, where a layer of functionating air-cells interposed between the focus of the infection and the dry hot air apparatus, would fail to respond to the treatment as well as the ordinary form where the consolidated area constitutes a practically solid tissue continuous with the external skin, thus facilitating conduction of the heat; and experience so far indicates that this also is true. In the small number of cases of this variety of pneu- monia that has come under my observation since I have been using this therapeutical agent, the reaction has been much less satisfactory ; but even here that benefit was derived was unmis- takable. There is another possible explanation of the effect of local dry hot air applications upon pneumonia, viz., that the direct and reflex acceleration of metabolic processes in and about the consolidation results in the immediate production of an acid reaction in the exudate whereby the development of the germ colonies would also be inhibited. As has been stated, the evolution of pneumic acid is a natural phase of the later stages Pneumonia. 137 of the phenomenon of consolidation, and the logical tendency of thermo-therapeutical applications would be to hasten the natural sequence of metabolic events. The former solution of the problem appears at present to be the more probable, but this one deserves consideration in this connection. It is significant, with reference to the foregoing, that Dr. Beverley C. Kinnear, of New York City, used heat with bene- ficial results in the treatment of pneumonia, in the form of hot- water bags or flannels wrung out of hot water, continuously applied, previous to 1898. His paper upon this subject was published in the Boston Medical and Surgical Journal for December 2, 1897. He made his applications over the dorsal sympathetic ganglia, and believed the effect to be due to reflex influence exerted upon and through these structures. Is it not possible, however, that the benefit was due, in part, at least, to a greater or less inhibition of germ growth through the raising of the temperature of the adjacent structures, muscles, pleurae, etc., and through those of portions of the contiguous consolidation ? The application of cold in the form of ice packed about the chest has also been employed with benefit in this disease. This measure would unquestionably exercise a certain amount of ip- hibitory influence upon the growth of pneumococcus colonies, by lowering, in some degree, the temperature of at least por- tions of the consolidated area, but it would not stimulate ab- sorption or metabolism; on the contrary, cold retards these processes, hence this measure would not be expected to produce the same degree of beneficial effect as intense dry heat. The patient's vitality, as represented by his reactive powers, con- stitutes a large element in securing a favorable effect from cold applications. When heat is employed, this factor does not enter the equation, as he has had nothing administered that demands reaction for the development of its benefits; its favorable influence is direct and inherent. An incontrovertible elucidation of the exact manner in which these effects of hot and cold local applications in pneumonia are brought about is at present impossible, nor is it necessary for our present purposes. The vital point is that they are 138 Therapeutics of Dry Hot Air. brought about, and that this is so is attested by a large number of competent clinical observers. General Application. Occasionally a case is encountered where the patient's excretory organs are incapable of eliminat- ing the toxins with sufficient rapidity, and a depression of nerve centers develops which threatens speedily to end the scene and the patient. This condition may be brought about by defective renal function, a low condition of the patient's vital powers when the infection was sustained, or a particularly virulent type of infection. Whichever the cause, the local treatment is ordina- rily useless, because it could not possibly influence the kidney to any degree when applied to the lung ; the small area of skin subjected to its influence does not contain enough nerve end- ings to make possible a reflex stimulation of the spinal centers profound enough to overcome a general debility of this char- acter ; and, as has been seen, the most virulent toxins emanate from the youngest colonies of germs, which are so placed in the periphery of the area of consolidation as to be beyond the penetrative limit of the local application. The only resource then becomes the induction of profuse and rapid elimination from a larger area of the skin, a rousing of the kidneys and lungs to increased function, and a strong stimulation of the spinal centers which are being overwhelmed, and the body dry hot air treatment enters the arena. As will be seen by referring to its physiological action, it possesses the power to accomplish all of these objects in an eminent degree, and the method of its application will be described in a subsequent section. ILLUSTRATIVE CASES. The following instance exemplifies very well the effect of the local application upon the ordinary case of pneumonia : Case I. Mr. G. W. P., age thirty-four years, a clergyman by occupa- tion. I saw the patient first on March 29, 1900, at 9 A. M. He had been in his usual health until the preceding evening, when he had begun to feel " badly all over," and had noticed a sharp pain under his left nipple. This had grown worse dur- ing the night, and towards morning he had begun to cough Pneumonia. 139 some, which increased the pain, as did also deep respiration. Auscultation and percussion elicited nothing abnormal. His pulse was 76 per minute, respiration 20, temperature 98.6 F. It looked like developing influenza, and the patient was sent to bed and an anodyne cough mixture prescribed. March 29, 7 p. M. The cough had increased during the day and the pain under the nipple was now harassing in the ex- treme. Severe headache had developed, but there was no ex- pectoration. Pulse was 100 per minute, respiration 48, tem- perature 101.6 F. Physical examination discovered a few crepitant rales and a marked pleural creak, but no dullness. I made a diagnosis of commencing pneumonia, directed that a hot-water bag be applied over the site of the pleurisy, and that five grains of antikamnia be given every hour until the headache was relieved. . March 29, n P. M. The pain had lessened somewhat under the influence of the hot-water bag and ten grains of anti- kamnia, and this drug was then discontinued. Slight dullness had developed over the lower lobe of the left lung. Pulse was 98, respiration 48, temperature 100.6 F. March 30, 8 A. M. Patient had been very restless during the night, and had slept but little. Headache and pleuritic pain had increased after midnight, and were now again extremely harassing. He was expectorating a green viscid mucus, which adhered to the bottom of an inverted dish. Pulse was 100, res- piration 42, temperature 100.8 F. Dullness was now marked over lower lobe of left lung. Patient was greatly prostrated, and his pain, frequently exacerbated by coughing, was increasing his prostration, but I hesitated to give him morphine because he was of a mark- edly neurotic temperament, and I also feared the respiratory depression so frequently dependent upon its administration under these conditions. I decided to try Baume Analgesique, applied over the pleurisy with a hot-water bag over it, and directed that I be notified if no amelioration occurred by n o'clock A. M. I was so notified, and decided to treat the consolidated lobe with dry hot air, which was done at noon. At the end of the treatment the pleuritic pain was entirely relieved, except when coughing violently or upon forced respiration, and the pulse had dropped to 96, respiration to 28. During the morning the sputum had become blood-stained, and was now typically pneumonic. March 30, 8 p. M. The pleuritic pain had remained in abey- ance until 6 P. M., but had been very severe since. Pulse was loo, respiration 56. temperature 103 F. Dry hot air was again 140 Therapeutics of Dry Hot Air. administered, completely relieving the pain as usual, and at the end of the treatment the pulse was 94, respiration 38. I left the patient resting quietly. March 31, 9 A. M. He had continued to rest comfortably until 2 A. M., when the pleuritic pain had begun to return, and it was now severe again. The cough had greatly lessened and what little sputum he raised was rusty and very tenacious. Pulse was 96, respiration 32, temperature 102.2 F. The dull- ness over the affected lobe was markedly less, and numerous coarse rales were present. Dry hot air was administered. March 31, 9 P. M. Patient had no pleuritic pain during the day, but at 8 p. M. it had returned nearly as severely as before. Sputum had become much lighter in color during the after- noon, and was much less tenacious. Percussion betrayed only a very small area of slight dullness over the affected lobe, and the coarse rales, so plentiful in the morning, were disappear- ing. Pulse was 100, respiration 30, but had dropped to 28 at noon, and temperature was 102.2 F. Dry hot air was admin- istered. About fifteen minutes after treatment was begun the pleu- ritic pain disappeared, and patient remarked how good it seemed to be free from it. Shortly afterward he exclaimed, " Oh, how queer I feel ! " I asked him what the matter was and he tried to, but could not answer. His eyes closed, muscles re- laxed, and he appeared to have fainted. I felt the pulse ; it was very soft, and the respiration, as well as the pulse, had be- come very slow. His lips were blue and the skin on the face ashen. I immediately removed the apparatus, threw the clothing from his body, and had the nurse fan him vigorously, while I opened a window and got a hypodermic of strychnia ready. It was not needed, however, as in a minute or two he revived, opened his eyes, and his pulse and respiration re- sumed their former rate and character. By evening of the next day, April i, the physical signs of consolidation had entirely disappeared, but rales were still present, and they persisted in some degree in this situation for about a week. From this time until April 4 the only noteworthy event was an acute oedema of the lungs, lasting about six hours, which occurred in the morning of April 2. For thirty-six hours previously the patient had suffered from a headache which had utterly resisted the ordinary analgetics, and which had become so severe that I was obliged to resort to morphine hypodermi- cally during the night of April i. The oedema yielded to hypo- dermics of strychnia and atropin in about five hours. Shortly after midnight of April 3 the patient became slightly Pneumonia. 141 delirious, and about three o'clock in the morning of April 4 pleuritic pain appeared over the lower lobe of the right lung. I saw him at 8 A. M., at which time his pulse was 104, respira- tion 38, temperature 102.4 F. The original focus of infection in the lower lobe of the left lung was in a satisfactory condition, but dullness had appeared over the lower lobe of the right lung. I called again at noon and found that the dullness which was present in this situation in the morning had in- creased to flatness, and the sputum was bloody. The general condition was about the same as in the morning. Dry hot air was applied over the lower lobe of the right lung. April 4, 10 P. M. Patient had passed a very comfortable afternoon. Sputum was rusty. Pulse 106, respiration 36, tem- perature IOI.6 3 F. The flatness over the lower lobe of the right lung had decreased to dullness, and dry hot air was adminis- tered again in this situation. During the evening Dr. Rollin McNeil, of New Haven, saw the case with me in consultation, and did me the honor to observe its subsequent course. As the patient was excessively prostrated, I remained with him dur- ing the night. April 5, 8 A. M. Patient had developed a severe lumbar myositis in both sides, but especially marked in the right, which had first manifested itself about 4 A. M. Spasms in the affected muscles were frequent and painful, and extreme ten- derness to the touch was present. I directed that mustard pastes be applied over the affected structures. April 5, 10 P. M. Muscular spasm and pain had been only slightly relieved by the sinapism, and the patient had suffered considerably from them during the day. The slightest move- ment on his part, or manipulation by anyone else, would set up the spasm. Pulse was 94, respiration 34, temperature 100.2 F., and general condition much the same as in the morn- ing. Physical examination demonstrated that dullness was present only in spots over the lower lobe of the right lung, and that air was entering pretty freely every part of it. Dry hot air was administered again and the cloth attach- ment was carried downward and backward so as to include the inflamed muscles. At the end of the treatment the patient could cough, respire deeply, and move about in the bed, and the parts could be manipulated without causing spasm or pain. The patient's continued extreme prostration decided me to remain again by his bedside during the night. April 6, 8 A. M. Patient had passed a very comfortable night, sleeping most of the time. Had suffered slightly from muscular spasm about 2 A. M., but at this time only very slight soreness upon manipulation was apparent, and patient could 142 Therapeutics of Dry Hot Air. move freely without exciting any spasm or pain. Sputum had lost its rusty character and was opaque, whitish, and somewhat frothy. Pulse 92, respiration 28, temperature 99.2 F. Dull- ness had disappeared entirely from the lobe last affected, but some rales were still present in this and also in the lower left lobe. From this time on the patient's recovery was steady and uneventful, except for a short, but pretty sharp, return of the myositis on April 8, which was readily controlled by dry hot air locally. The temperature returned permanently to the normal on April 22, with a pulse of 76, and respiration of 18, but it had not been higher than 99.2 F. after April 4. The extreme prostration, which had caused me so much anxiety on April 5 and 6, had disappeared rapidly after April 8, and the convalescence was entirely satisfactory in every respect. It will be observed that in this case the administration of dry hot air was followed by the results noted below. First, immediate relief of the pleuritic pain, which relief lasted for several hours after treatment. Second, a decrease in the frequency of respiration, probably due to relief of the pleuritic pain, and which on the evening of March 30 amounted to twelve cycles per minute. Third, lessening of the cough. Fourth, a drop in the body temperature amounting to from half a degree to one degree, F. It will be observed that after the second treatment the temperature did not at any time rise above 102.2 F. until the morning of April 4, when the right lung became involved, and even then it only reached 102.4 F., an unusually low temperature for an ordinarily severe case of pneumonia. Fifth, entire disappearance of the physical signs of consoli- dation within forty-eight hours after the first treatment was administered. It also exemplifies, during the administration of the treat- ment on the morning of March 31, the cardiac disturbance that sometimes occurs when the lower lobe of the left lung is being treated. As previously stated, when profound general toxaemia is present, the general application is the measure to be employed, but that the influence of the local application upon the toxin- Pneumonia. 143 producing factors at the site of infection is, in rare instances, sufficient to avert a fatal termination was evidenced by a case which occurred in the practice of Dr. B. S. Lewis, of New Haven, Conn. Case II. The patient, a woman, about fifty years of age, had been suffering from pneumonia in the lower lobe of the right lung for several days and had become comatose from toxaemia dur- ing the late afternoon of May 4, 1900. Dr. Lewis called Dr. Rollin McNeil in consultation upon the case ; they agreed that no ordinary therapeutical measure offered any hope of saving the patient's life, and invited me to administer dry hot air. I repaired to the patient's bedside at once, in company with the gentlemen just mentioned, and administered the first treat- ment at ii o'clock, P. M. At this time the patient could not be aroused, subsultus tendinum was present, her pulse was 130, weak, compressible, and thready, respiration 33, and she was evidently failing rapidly ; no pleurisy was or had been present. The pulse improved before the treatment was concluded, and shortly afterward the nervous symptoms decreased, but the respiratory acceleration showed no sign of abatement for sev- eral hours, probably because no portion of it was due to pleurisy. When we called to treat her again the next morning she was conscious, the pulse and other symptoms had continued to improve, and she went on to convalescence and complete recovery. Other cases in which I have relied upon the local application to overcome profound general toxaemia, however, have died, and I do not now consider it justifiable to postpone the body treatment under these conditions. One of the fatal cases just referred to, occurring in the practice of Dr. Walter C. Skiff, of New Haven, Conn., was of particular interest because of the fact that the physical signs of consolidation had almost entirely disappeared eighteen hours after the agent was first applied, yet the patient died in a few hours just the same ; a bit of evi- dence tending to confirm the hypothesis that the most virulent of the toxins emanate from the colonies of pneumococci at the periphery of the region of infection, and which are beyond the reach of the inhibitive influence of the local application, as de- scribed in a preceding section. 144 Therapeutics of Dry Hot Air. TREATMENT. Local Dry Hot Air Application. The local application of this agent is, in many cases, the only thermo-therapeutical measure required in pneumonia, and the appropriate technique is as follows : A piece of cheap Turkish toweling, four or five feet long and eighteen or twenty inches wide, is folded twice, so as to make three thicknesses, and applied closely against the skin over the affected portion of the lung. This is held in place by two or three pieces of webbing one inch in width, supplied with buckles at one end, and long enough to pass clear around the body. The patient is then brought close to the edge of the bed and supported by pillows in such a way that the apparatus can be attached directly over the area to be treated. The heat should be run up to from 275 F. to 350 F., according to the patient's tolerance, and the duration of the treatment should be from half an hour to an hour. Victims of this disease find it extremely irksome to lie in one position with the affected lung uppermost, for an hour, but the treat- ment' should be continued for this length of time if it can be done without provoking undue exhaustion, and judgment and experience must govern on this point. Treatments of less than half an hour are of little, if any, use. When treating the lower lobe of the left lung, it should be borne in mind that acute dilatation of the heart is sometimes induced, either by reflex influence or conduction of the heat to the organ through the area of consolidation, and the pulse and respiration should be constantly watched. If untoward symptoms appear, the apparatus and wrappings should be im- mediately removed, and the patient's body exposed and fanned. Usually this will take care of the condition in a few seconds, when treatment may be resumed. If the patient does not revive at once, towels wet in cold water should be slapped over the chest and abdomen, and strychnia injected hypoder- matically. After-Care. When the treatment has been completed, the capillary area which has been subjected to its influence will 0, !H O be a. a, J Pneumonia. 147 be found to have become deeply injected and covered with pro- fuse perspiration. This secretion will also usually be in evi- dence to some extent on other parts of the body. It may be removed with a dry towel, the area treated wrapped in one thickness of flannel, and the patient made comfortable again in bed, but no other after-applications are necessary. It will be seen that poultices and pneumonia jackets are entirely uncalled for when dry hot air is obtainable, hence the patient and his attendants are spared the exposure and discomfort contingent upon their use. The application should ordinarily be repeated every twelve hours for the first two days, and once daily thereafter until convalescence is established. General Application. The patient is prepared for treatment in the usual way and placed in the apparatus, and the heat is run up as rapidly as possible to 275 F. or 300 F. If perspira- tion or marked flushing of the face is not induced by this tem- perature, the same should be increased until it is, or until the patient's tolerance is reached. The treatment should last from twenty minutes to three-quarters of an hour, according to the effect produced. As the body temperature of the patient is usually already high when he enters the apparatus under these conditions, it is useless as a guide to the duration of the seance, and the pulse and general effects must be relied upon for guidance; another situation where good judgment and experience are friends in need and in deed. In a general way, however, it may be said that the pulse should not be accelerated beyond 140 beats per minute, and that when sedation of the nervous system or dila- tation of the capillary circulation as evidenced by decided flushing of the face or general perspiration has been induced, it is time to stop. Over-stimulation means exhaustion, which should be avoided, and a patient in the extremity we are con- sidering is especially susceptible to its induction. The after-care does not differ from that of the body treat- ment in general. The beneficial influence of the treatment upon the heart and nervous system is frequently apparent while the patient is still in the apparatus, and it lasts from twelve to 148 Therapeutics of Dry Hot Air. twenty-four hours usually. The application may be repeated when the patient begins to fail again. Heart Failure. This symptom is sufficiently important to merit brief special mention in this connection. It is due either to massive exudate or systemic toxaemia, or a combination of both. Massive exudate will usually yield to the influence of the local treatments with sufficient readiness to save the patient, but these applications are not effective in relieving the symptom when due to systemic toxaemia. The body treatment only is efficient here, and in view of the fact that the patients almost always die under all other methods of treatment when reduced to this extremity, it is justifiable to move them in an ambulance from their homes to a hospital if they cannot be gotten to a body apparatus in any other way. As the treatment would be applied immediately, the evil result of any ordinary exposure sustained during the journey would be remedied at once, and the patient would thereby get the benefit of almost the only therapeutical measure that offers him a reasonable hope of recovery. Additional Remedial Measures. The other forms of physical therapeutics never enter the problem of the treatment of this disease when dry hot air is obtainable, but medicines are important. Drugs. Professor A. H. Smith, cited previously, advocates the administration of drugs which are excreted largely by the lungs, and which are inherently inimical to the development of the pneumococcus. The extreme sensitiveness of this organism to conditions pervading its pabulum renders several drugs avail- able for this purpose, among which may be mentioned creosote carbonate, the salicylates, large single doses of calomel, and quinine ; under ordinary circumstances the administration of these substances is not deleterious to the patient. The two first mentioned are Professor Smith's choice, the clinical results he reports are excellent, and the author desires hereby to add his testimony to that of other observers, as re- gards the favorable influence of creosote carbonate, at least. The weak point in this method of attacking the germs is that Pneumonia. 149 some stomachs, kidneys, and nervous systems cannot stand the drugs advocated in sufficient quantities to render possible the induction of their antiseptic influence, and that medicines ex- creted in this manner do not penetrate to the germ colonies deeply located in the consolidated area. They do, however, reach the youngest of the colonies, which are spreading at the periphery of the consolidation and giving rise to the most virulent of the toxins. As we have seen, dry hot air treat- ments exert their most powerful influence upon the area of consolidation, hence, by combining these with the administra- tion of appropriate germicidal drugs, we secure the most effect- ive inhibitory influence possible at the present time. The drug management of the symptomatic phenomena of the disease does not differ from that applicable under other circum- stances. Strychnia, whisky, sanguinaria or sanguinarin, small doses of tartar emetic, bryonia, phosphorus, etc., all have their places as stimulants, expectorants, etc., but when dry hot air is given they will sometimes never be indicated at all, and when they are it will be for a shorter time and in much smaller quan- tities than under other conditions. When the respiratory area has been greatly encroached upon, oxygen inhalations are extremely helpful and constitute a fairly efficient nerve stimulant as well. CHAPTER VIII. ALBUMINURIC NEPHRITIS (BRIGHT'S DISEASE). Modifications of Clinical Conditions producible with Dry Hot Air. Local Application. This measure exercises no appreciable influence upon the essential characteristic symptomatology or pathology of the disease, and may be dismissed at once from further considera- tion in connection therewith. General Application. First, relief of the headache, nausea, respiratory and cardiac embarrassment, sometimes before the patient leaves the appa- ratus, and usually within twelve hours. Second, increase of the urinary excretion and of the total urea output in cases wherein these factors are deficient, whereby the general tox&mia is lessened. Third, diminution of the total quantity of albumin voided in the urine, at least when such quantity is large, and sometimes complete elimination of this abnormal constituent. Fourth, diminution of the dropsy within twelve hours usually, and sometimes its entire disappearance within four or five days. Fifth, absence of the evil after-effects of drugs which it is sometimes necessary to administer for the control of severe symptoms, because such symptoms are effectually removed by dry hot air, which produces no vicious reaction when judi- ciously and properly administered. Sixth, restoration to perfect health of some of the victims of this disease, and to apparent health and unimpaired use- fulness of a large number. RATIONALE OF THERMOTHERAPY. Etiology. Unfortunately, a positive knowledge of the pri- mary etiological factors of this disease is not available at the 150 Albuminuric Nephritis (Bright* s Disease). 151 present time, but the general symptomatology and local tissue alterations are such as to point with a strong degree of prob- ability to the presence in the blood of some bodies irritant to the renal structures during excretion, and which are devel- oped in the tissues by reason of some disorder of the sympa- thetic nerve centers which govern the functions concerned in tissue metabolism, more particularly oxidation. If this proves to be true, the disease will ultimately have to be transferred from the category of the renal to that of the constitutional disorders; an impairment of general metabolism, of which the changes in the kidneys are but secondary local manifestations. The manner in which the disease responds to dry hot air applications strengthens this conception of its causation, as does also the fact that the only therapeusis that has ever been of value in the condition is that which has had elimination of some sort, or increase of oxidation in the body as its object. The clinical aspects of the disease are also strongly indicative of systemic toxaemia of some sort. Speculations as to the primary etiology of the disease are at present fruitless, however, and fortunately positive knowledge upon this point is not necessary, so far as the use of dry hot air in its treatment is concerned. We can derive an ample num- ber of rational indications for its employment from the well- known clinical phenomena. Symptomatology and Pathology. Let us consider briefly some of the most prominent and constant of these clinical man- ifestations, and see if it is possible to deduce anything as to the causative factors, which will constitute a logical basis Mpon which to construct a rational therapy. First, there is frequently present dyspncea of variable degree, which might be due to pressure upon the pulmonary innerva- tion, interference with the respiratory movements through fluid accumulations in the abdominal or pleural cavities, or ir- ritation of the nerve endings in the pulmonary mucosae by the excretion of abnormal, irritating bodies from the blood current. In most cases the first two of these possible causative factors can easily be excluded. Second, dropsy, which might be due to change in the blood COLLIEGII Ct r L=K\ SlCLwUfc CHU 152 Therapeutics of Dry Hot Air. pressure from insufficiency of the cardiac or arterial impulses, changes in composition of the blood serum, or irritation of endothelium from toxic bodies circulating in the blood current. Third, digestive disturbances, which could also be due to excretion by the alimentary mucosa of toxic bodies present in the general circulation. Fourth, a variable degree of bronchitis, indicating an abnormal, irritant condition of the excretions of the pulmonary mucosae. Fifth, affections of the skin, explicable upon the assumption of either trophic aberration, or the presence in the integumen- tary excretion of abnormal, irritant matters. Sixth, a quickened heart action, accompanied by increased arterial tension, easily explicable upon the assumption that the blood current holds in solution some irritant body or bodies. Seventh, headache, dizziness, insomnia, increased general nervous and muscular irritability, sometimes eventuating in the most pronounced convulsive seizures ; all strikingly indica- tive of the presence of toxic contamination of the body fluids. Eighth, the total urinary output in the ordinary chronic form of the disease, is usually somewhat in excess of the normal, with lowered specific gravity, a phenomenon easily interpret- able as the result of renal irritation, due to the presence in the blood of an abnormal toxic element. In the more acute seizures or exacerbations, a diminution in quantity obtains which reaches the point of complete suppression when the inflamma- tion of the secreting structures attains a sufficient degree of intensity ; and this inflammation again is undeniably dependent upon some antecedent irritation. Ninth, the fact that albumin is usually found in the urine is explicable upon the same causative hypotheses advanced in con- nection with dropsy, one of which, it will be remembered, in- volved the presence of some irritating body in the general circulation. Tenth and last, the structural changes in the kidneys of true Bright's disease are just such as we should expect to find as the direct or remote result of inflammatory action, which again Albuminuric Nephritis (Brig/it's Disease}. 15.3 presupposes the presence of the element of antecedent irrita- tion. A general debility of varying degree, frequently amounting to profound prostration, also usually accompanies the develop- ment of the renal symptoms. We have, then, ten of the cardinal elements which combine to form the clinical and pathological picture of Bright's disease of the kidneys, and four of the minor symptoms, for the ex- planation of every individual one of which the hypothesis that an abnormal substance or substances possessing toxic and irri- tant properties is contaminating the general circulation would be sufficient; and I do not know of any evidence tending to show that such a product and condition do not exist in this situation, or that their existence would not be sufficient to explain all of the pathological and clinical phases of this ail- ment. Nature of Specific Toxin. The next inquiry that would naturally follow in this line of reasoning would be, " What is the nature and evolution of this abnormal toxic irritant ? " We find that the urine of Bright's disease commonly exhibits a deficiency in the quantity of urea normally present, and the first thought would be that accumulation in the blood of an in- tolerable amount of this product of catabolism was the offend- ing factor. Indeed, this view of the matter has been very gen- erally accepted until recently, but there exists some evidence tending to show that another solution of the problem invites consideration. First, although the urine is deficient in urea, yet that does not necessarily prove that the missing quantity has been re- tained in the blood, as urea. Second, it has been found that urea injected into the veins of animals produces scarcely any general disturbance, unless the kidneys have been extirpated or their blood-vessels tied off. Third, although death always follows the extirpation of both kidneys or ligation of their blood-vessels, yet this does not necessarily prove that death, under these conditions, is due to retention in the blood of urea, and further, uraemic phenomena 1 54 Therapeutics of Dry Hot A ir. do not by any means always accompany dissolution under these conditions. The element of shock, which the total destruction of an element so vital to the preservation of the organism as is the renal function, would enter into the problem with a force that cannot be estimated, and that might in itself, and exclusive of all other causes, be sufficient, in its remote reflex and indi- rect influences upon other functions and the general bodily metabolism to produce death. Fourth, cases of complete suppression of the urine for periods varying from five to twenty-five days, and exhibiting no increase in uraemic signs, are not so very uncommon in medical literature. In these cases the blood is frequently loaded with urea, and increase in the uraemic symptoms could hardly fail to appear if urea were the active cause of them. Fifth, although the induced perspiration of Bright's disease is said to exhibit a marked increase in its toxic properties, yet the quantity of urea found therein bears no adequate proportion to the amount of benefit frequently dependent upon the in- duction of perspiration. Sixth, urea in excess is by no means always found in blood drawn during uraemic seizures. Seventh, urea is a normal, therefore an unirritating excre- tory product of the kidneys, and no evidence is at hand to in- dicate that these organs would be unable adequately, and with safety to themselves, to excrete any amount of it which the bodily metabolism was capable of elaborating, or that urea, in itself, is capable of provoking inflammation in these organs, however great the quantity which they may have been called upon to dispose of; and inflammation of the renal excretory structures of some degree is an invariable concomitant of uraemic manifestations. Eighth, if we assume that an excessive amount of urea in the blood is the essential causative element of uraemic phenomena, we must necessarily also assume that one of two antecedent conditions obtains in order to account for its presence there : First, that the primary and initial lesion is the inflammatory process in the kidney, by reason of which the kidney is so crippled tl.at it is unable to excrete the normal quantity, where- Albuminuric Nephritis (Bright 's Disease). 155 by the same is thrown back into the blood current; and there is no satisfactory evidence available to support this suppo- sition. Second, that some aberration of metabolic function causes urea to be elaborated in such quantities that the kidney is unable to excrete it ; and, as stated above, there is no conclusive evidence available to indicate that urea is so present, that it would be possible for the organism to elaborate urea in sufficient quantity to produce this effect, or again, that urea would be able in any possible quantity to produce the inflam- matory renal pathology which is always observed in this disease. These facts are vital, and any theory that does not satisfy their claims is not entitled to unmodified acceptance. Therefore, it would appear that there is justification for look- ing for something besides urea, as the direct exciting cause of uraemic phenomena, and as inflammation of the kidney struc- tures, which would partake of the nature of an external factor, can be disregarded as a primary cause, we must look for the origin at the other end of the equation, that is, within the body. Now, urea is a substance of a moderately high degree of oxida- tion, and, as the clinical phenomena of Bright's disease by no means constantly indicate that excessive oxidation is taking place, we must consider that it is among the sub-oxidation products or structural antecedents of urea that we may expect to find the characteristic toxin. Finally, it will be instructive, in this connection, to ascertain whether or not the actions of remedial measures which have hitherto been found useful, will shed any light upon the subject. This point may be disposed of very briefly, and as follows : Every therapeutical measure that has attained a lasting place in the popular management of this disease has exerted its prin- cipal influence toward the induction of one or more of the fol- lowing effects, viz. : First, increased elimination, as by diuresis, diaphoresis, and purging. Second, dilution of the body fluids, whereby the effect upon 156 Therapeutics of Dry Hot Air. the nerve centers of a toxin in the circulation would be less- ened, as by increasing the amount of water ingested, milk diet, etc., and by bleeding, which secures practically the same result as far as the toxin is concerned, but in another way. Third, as bearing more particularly upon the question of whether or not the toxin is a .sub-oxidation product, lessening the amount of metabolic elaboration demanded of the trophic nerve centers, as by restriction of the diet. Fourth, stimulation of metabolism, which, in this connection, means oxidation, by the administration of iron and other gen- eral tonics and the prescription of judiciously-regulated exer- cise. Another fact bearing upon this point is the well-known evil effect upon the victims of Bright's disease of administering any agent which exhibits a tendency to check oxidation or metabolism, as alcohol, coal-tar derivatives, etc. We find, then, that Bright's disease is a condition character- ized by, and the clinical phenomena of which are probably due to severe systemic toxaemia of some sort, and that the toxin concerned is probably a sub-oxidation product which would normally be elaborated into urea. The occurrence of sub- oxidation means, of course, impaired metabolism, and im- paired metabolism implies inefficient functionation of the sym- pathetic nerve centers, because it is under and through the control of these centers that metabolic processes are elabo- rated. Therapeutic Indications. The objects of treatment in Bright's disease, as indicated by the clinical phenomena and what is known of the pathology, would be, then, to secure . . First, an increase in vigor in the functionation of the deep trophic nerve centers, impairment of which is probably respon- sible for the presence in the body of toxic products of imperfect metabolism. Second, a direct increase of the oxidation processes in the body, whereby it will be possible to elaborate the chemical structure of the toxic bodies to a point which will admit of excretion without irritation ; in other words, to oxidize them 'into urea. Albuminuric Nephritis (Bright 's Disease}. 157 Third, to secure as active an elimination as possible, in order that the system may be relieved of as much of the toxin as possible in the shortest possible time. General Application. Theoretically, this procedure should constitute an ideal therapeutical measure in connection with Bright's disease; it apparently satisfies all three of the indica- tions for treatment. Practically it does not prove to be as profoundly and uni- formly curative as might be expected from its physiological action, but even under such limitations it is the most effective and satisfactory remedy now at our command, especially in acute cases and exacerbations of the chronic form. In cases characterized by large amounts of albumin in the urine, and deficiency in the urea output, the former constituent lessens markedly soon after the treatment is inaugurated, and the latter is increased sometimes one hundred per cent, during the twenty-four hours succeeding the first application. In chronic cases, exhibiting a practically normal urea output, no increase in this excretion, and no very marked or immediate diminution in the quantity of albumin, may be apparent, but the evidences of toxaemia, such as headache, dizziness, etc., dis- appear rapidly. The patient is restored to usefulness and enabled to resume his daily occupation, even when the same involves pretty strenuous application, but albumin may persist in the urine for years. Some of these cases are restored to apparently perfect health. ILLUSTRATIVE CASES. Acute Albuminuric Nephritis. Case I. G. B., aged fifteen years, was brought to the sanitarium on April 6, 1904, by Dr. W. S. Randall, of Derby, Conn., at four o'clock P. M. The history of the case up to that time is quoted from a letter written me by Dr. Randall on November 9, 1904, as follows : "I was called on February n, 1904, to attend this boy, and found him with a high fever ; forty-eight hours after a rash appeared and a diagnosis of scarlatina was made. He was given the treatment usual in such cases tr. ferri. chlor., a 158 Therapeutics of Dry Hot Air. gargle for his pharyngitis, and kept in a warm room under the care of a nurse. A light and easily digested diet was ordered, and an antiseptic ointment applied to the body at intervals. " All went well, fever subsiding and patient beginning to get about his room and take more food, until about March 6th, when oedema began to show itself about his feet and ankles. Urinalysis showed small percentage of albumin, the total quan- tity of urine passed being small in amount, and of high specific gravity. " Diuretics and Basham's mixture were given, which seemed to relieve the early stages, but, as the case progressed, the oedema extended up the body, involving the thighs, hips, and scrotum. Dry cups over the kidneys and sweating were freely used, and some relief resulted apparently, but still the oedema persisted, and the patient seemed to make but little headway. " Thus the case ran along, improving somewhat, until March 27th, when it was decided to move him to his home, he having been in a boarding house up to this time. A little cough had developed, and some shortness of breath was then present. " After his removal in a close carriage, a distance of one and a half miles, he seemed rapidly to get worse. Dyspnoea and cedema increased, marked dullness developed over the lower chest wall, and abdomen became distended. The kidneys were getting into an intensely congested state, as was shown by the presence of a high percentage of blood in the urine. " Diuretics, saline cathartics, and heart stimulants were freely administered, with only temporary relief. " From this time the case grew steadily worse, until, on the 5th of April, I was suddenly called to his bedside to find him suffering from extreme dyspnoea, and in such an alarming condition generally that I did not expect him to live until the following morning. I administered an hypodermic of mor- phine and atropine, which temporarily relieved his paroxysm, and the following day after a hurried consultation over the telephone I took him to your sanitarium for dry hot air treat- ment." When this patient was admitted to the sanitarium the follow- ing conditions obtained : Marked prostration and urgent dyspnoea, which forced him to maintain an erect sitting posture and made speech a matter of considerable difficulty; patient was coughing constantly, lips were cracked and covered with large, bloody scabs. His pulse was 124, weak, intermittent, and irregular, mouth temperature 99.2 F., respiration 52. The body was oedematous throughout, but especially so in the legs and feet, the last-men- tioned members being about twice their natural size. Coarse Albuminuric Nephritis (Bright 's Disease}. 159 rales were diffused over both lungs and marked dullness, almost flatness, presented over their lower portions. He was passing a small quantity of very dark brown urine of specific gravity 1001, which contained a large amount of albumin, some cylindroids and degenerated cells, a few hyaline and many granular casts, red blood cells, and small round cells from the renal tubules. It was, in short, a typical case of dangerously severe acute nephritis, so severe that Dr. Randall " did not expect him to live until the following morning " the night previous ; he afterwards told me that he was very doubtful as to his ability to get him to the sanitarium alive. He was given a body dry hot air treatment at once; one- tenth of a grain of calomel combined with sodium carbonate was administered every half-hour until one grain had been ingested, one-sixtieth of a grain of strychnia sulphate every six hours, and one-eighth of a grain of morphine combined with atropine was given hypodermically three times . during the night. His diet was cut down to milk and beef tea. By the next morning a diminution of the dyspnoea, cough, and oedema was perceptible, and he had slept at intervals during the night a total of five and three-quarters hours, propped up by pillows; he felt and was appreciably improved. As the calomel had not acted, two drams of magnesium sulphate were ordered administered every two hours until the bowels moved. At 10 A. M. his pulse was 112, mouth temperature 99 R, res- piration 36. At ii A. M. another general dry hot air application was administered; at 4 p. M. the bowels moved loosely and freely, and at 5 P. M. one-fortieth of a grain of strychnia sulphate was administered, the preceding dose having been given at midnight. The improvement in the symptoms noted in the morning had increased during the day, the patient now being able to recline upon his bed propped up by pillows. A noticeable decrease had also obtained in the dullness over the pulmonary areas and in the number of rales audible. The urine passed during these first twenty-four hours meas- ured two pints, of specific gravity 1001, color very dark brown with coffee-grounds sediment, and it contained a large amount of albumin, numerous casts and red blood cells. To make a long story short, this patient was under treat- ment at Newhope one week, during which period he was given four general dry hot air treatments, three static induced electri- cal applications over and through the kidneys, and three static wave current applications to his spine. The first electrical treatment was given at noon of the third day, so that no part 160 Therapeutics of Dry Hot Air. of the very significant modifications of symptomatology noted during the period preceding can be in any degree attributed to electricity. After the first twenty-four hours, the only medicine admin- istered was one-sixtieth of a grain of strychnia sulphate every six hours and magnesium sulphate in two-dram doses every two hours, when it was necessary to move the bowels. One movement a day was all that it was attempted to produce. The diet throughout consisted solely of milk, beef tea, chicken broth, a little rice, and a small piece of stale bread once daily. From a pint to a pint and a half of water was administered, in small quantities at a time, during the twenty- four hours. The improvement, the inauguration of which is described above, steadily continued until he was discharged, when he went home to Derby, a distance of ten miles, on a trolley car, walking from the sanitarium to the cars a distance of half a block. The dyspnoea and cough had entirely disappeared, and, during the last three nights of his stay, he had slept lying down in bed; the oedema of the lungs and effusion into the pleural cavities had entirely disappeared, and the dropsy had vanished from all parts of the body except about his ankles and feet. He was as hungry as any healthy boy of his age could be, begging for something to eat with tears in his eyes. The urine passed during the second twenty-four hours meas- ured three pints, as contrasted with two pints during the like period of time preceding, of specific gravity /oop, as contrasted with 1001, tzvo per cent., by volume, of albumin in place of the large amount contained in the preceding specimen, and a de- cided lessening in the quantity of blood and number of casts present. That passed during the third twenty-four hours measured eight pints, exhibited a specific gravity of 1006, a trace of albu- min so small as not to be susceptible of exact determination by the ordinary methods, and estimated at one-eighth of one per cent., and no casts. From this time until he was discharged the quantities passed during the successive periods of twenty-four hours varied from three to six pints, the specific gravity from 1006 to 1010, with a small trace of albumin and an occasional cast. The progress of the case since leaving us is thus described by Dr. Randall, who thereafter had him in charge. " After his return he was put upon a strict milk diet, given freely of water, and a tonic treatment administered. The static current was used twice a week over region of kidneys from April 3oth to July i6th, 1904. The urine gradually Albuminuric Nephritis (Bright' s Disease). 161 cleared from the blood cells and albumin, and the last examina- tion on July 1 6th showed no trace of either. He has remained well ever since." Although this case constitutes very good evidence as to the value of general dry hot air applications in acute Bright's disease, yet it by no means exhibits the almost magical changes that are sometimes producible in its symptomatology by the employment of this agent. The following is an instance in point : Case II. Mr. E. K., aged forty-eight years, was admitted to the sani- tarium for treatment at noon, January 13, 1902. Three months previously he had begun to notice that his feet were swelling, that he was having occasional headaches, attacks of vertigo, and difficulty in breathing during exertion, but thought little of it, as he was very fleshy. The symptoms shortly increased to such an extent that he consulted a physician, who recog- nized the trouble, judging from his prescriptions, but did not inform the patient. He continued to grow rapidly worse under treatment, and soon after consulted another with a like absence of results as far as improvement was concerned. Upon his admission his condition was one of great gravity. He had been unable to attend to his ordinary duties for three weeks. The subcutaneous tissues all over the body were greatly distended and fluid was present in the abdominal and pleural cavities. Respiration was irregular, nearly impossible in the recum- bent, and very difficult in the upright positions, and ranged from thirty-six to forty cycles per minute. Pulse small and wiry, irregular, and from 100 to 115 per minute. The least exertion brought on alarming acceleration and embarrassment of both respiratory and cardiac functions. Temperature 99.1 F. Patient was profoundly prostrated. Weight j 0*. 2, O < i 3 5' OQ Arthritis De for mans. 181 fact that the disease is no longer to be classed with those that are not amenable to treatment. Inconstancy of Symptom Complex. We will close this brief section upon the exceedingly important problem of diag- nosis by calling attention to the following additional facts which bear upon this point. Although in the commonest form of the disease, which occurs almost exclusively in patients over forty, the small joints are XXVI. Arthritis Deformans of the Knee (from a radiographic stand- point the position of the joint is faulty, but the plate illustrates very well absorption of the joint cartilage ; in radiographs of the normal knee the presence of these cartilages causes a large clear space to intervene between the patella and the articular surface of the femur anteriorly ; in advanced arthritis deformans of this joint the patella appears to rest directly upon the femur as above shown). first attacked, and the lesions are nearly always bilateral, yet this is not necessarily the case in all forms of the trouble. An attack may commence in the larger joints, run its course, and 1 82 Therapeutics of Dry Hot Air. recover without having involved the smaller joints at all; or it may be confined entirely to one large joint, as the hip for instance. Some of the severest cases are of this character. While the onset is usually gradual, with a beginning so insidious that the patient is not aware that anything is wrong until a wrench calls his attention to the sensitive member, yet it may develop as suddenly as acute articular rheumatism, and lay the patient helpless upon his bed in a night. When the disease attacks a person under thirty years of age, it usually involves both large and small articulations, and in these cases the worse phases of the disease and those most resistant to treatment are encountered. Therapeutic Indications. The objects of treatment deduci- ble from the foregoing would be as follow : First, to relieve pain. Second, to increase the efficiency of the trophic functions, and maintain the general nervous system of the patient in as good a condition as possible. Third, to clear the system of sub-oxidation products. Fourth, to relieve joint disability. Local Application. As this disease is not of local origin it would hardly be expected that this measure would exercise any positively curative power in uncomplicated cases, and our personal experience with it has led us to conclude that this inference is correct. I have never seen but one case in which curative effects could justly be attributed to it, and it was ulti- mately necessary to call upon the body treatment in this case before it could be brought to a successful termination. Its power to relieve local stasis of the body fluids and to effect sedation of nerve tissue sometimes causes it to be very useful as a pain-relieving agent, and occasionally it performs this function better than anything else. Its possible efficiency in any given case can be ascertained only by trial. General Application. In our opinion, the body dry hot air application is to-day the sheet anchor of hope in the manage- ment of arthritis deformans, because through it is obtainable in largest degree the stimulant influence upon the trophic nerve centers and general metabolism which constitute the curative Arthritis Deformans. 183 element. Its physiological action, as will be recalled, may be summarized as follows: first, it produces an immediate and powerful stimulation of the vital physical signs ; second, a reflex stimulation of the functions of all the organs and tissues of the body, resulting in, first, a degree of elimination of urea and other excreta which is probably unequaled by that producible with any other measure now known, and second, an amount of reconstructive activity which would appear also to be in excess of that derivable from the use of other agents. Ample logical indication for its employment is found when we consider these influences in connection with the therapeutic indications noted above. . There is usually present, first, a notable depression of the vital physical phenomena; second, impairment of function of many of the organs concerned in the digestive, elaborative, and assimilative processes of the body; and third, a marked deficiency in the reconstructive activities; the inferences suggested by the foregoing have been fairly well borne out by practical results accruing in actual ex- perience. ILLUSTRATIVE CASES. That form of the disease which affects the smaller joints is common enough and familiar enough not to require illustra- tion, but the following case exemplifies very well the variety which involves the larger joints, as regards clinical character- istics and response to treatment with dry hot air. Mrs. E. L. P., aged sixty-two years, consulted me on May 14, 1900. She had noticed a soreness coming on after walking, just below the crest of the right ilium, four months previously, which soreness had grown rapidly worse for two months, by which time it had extended so that it involved the front and inner aspects of the thigh as far down as the knee. It had continued to increase, both as to severity and extent of area involved, until at the time of her consultation with me the pain was present in the hip, groin, and front and inner aspects of the thigh, and streaked down below the heel along the posterior aspect of the leg; her condition as regards pain and ability to move about was pitiable in the extreme. Was sleeping very poorly because of pain and muscular spasm in her thigh which awakened her frequently during the night. Suffered fre- 184 Therapeutics of Dry Hot Air. quently from hot flashes and formications irregularly dis- tributed over the body. Appetite was fair and bowels regular. She was markedly neurasthenic, and had been so since passing the climacteric twenty years previously. At this time she had also suffered quite severely from asthma, but this had disappeared after a stay in another city, and had never returned. There was no history of injury. Mouth tempera- ture had ranged from 97 F., in the morning, to 99.6 F., at night. The extensor muscles of the thigh on the affected side had been somewhat stiff and sore upon pressure for the pre- ceding ten months, but she had not paid much attention to the matter until the acute and constant pain had drawn her atten- tion to the development of the disability. Had been treated for rheumatism up to this time, but without beneficial results. Her mother had died of consumption, and maternal grand- father was supposed to have died from it. She was one of a family of eleven brothers and sisters, seven of whom were dead, and their health histories and the causes of death were negative as far as indicating hereditary taint was concerned. Father had died of dysentery at the age of seventy-three years. Physical examination showed that the arcus senilis was well developed and that her radial arteries were atheromatous, but the heart sounds did not exhibit any abnormality and the lungs were sound. There were no evidences of past or present disease in the small joints, and no tenderness was present. She was unable to cross the right leg over the left knee without lifting it with her hand. Patellar reflexes were slightly in- creased, especially on the affected side. The characteristic pigmentation of the skin was present on the upper and outer aspects of the affected thigh and on the abdomen. Sensory phenomena in the skin covering the affected thigh and leg were normal. Passively moving the hip joint caused only a feeling of soreness, but smartly tapping the bottom of the right heel with the leg extended caused the patient to cry out, and firmly pressing the head of the femur inward against the acetabulum, or tapping it smartly, produced the same result. The sciatic nerve was sensitive to pressure back of the trochanter, but nowhere else, and deep pressure in the groin just outside of Poupart's ligament elicited pain. Her urine contained a trace of albumin, but no casts. It will be noticed that the characteristic signs of arthritis deformans of the hip joint were present, viz., inability to cross the affected limb over the opposite one unaided, while in a sitting position ; pain in the hip reflected into the groin ; pain upon pressing the head of the femur sharply and firmly against the acetabulum : the characteristic pigment spots in the skin. A rth rit is De for mans. 1 8 5 and the typical slight elevation of temperature with a regular course. The diagnosis lay between pelvic neoplasm involving the sacral plexus or its branches, which was ruled out by physical examination and the clinical signs; sciatic neuritis, which was excluded by the absence of sensory disturbances in the distribution of the nerve, and the fact that stretching it by flexing the thigh upon the body did not produce pain until the hip joint began to be strained; and tuberculosis of the joint. The decided localization of the intensity of the pain in the hip joint, together with the characteristic symptoms noted above, were amply sufficient for decision in favor of mon-articular arthritis deformans, and I made this diagnosis. She was admitted to the sanitarium for treatment May 15, 1900, four months after the acute trouble started. She was treated with the current from the high tension coil through the joint that evening, with resulting marked remission of pain, but she did not sleep well because of nervous irritability and muscular spasms in the affected thigh, which awakened her several times. The next day she was given a body dry hot air treatment, which did away with the pain entirely while she was in the apparatus, but it returned sharply an hour after- ward. This was repeated every day the first week, and every other day the second week. Local dry hot air treatments failed to relieve the pain effectually, so they were abandoned and the current from the high-tension coil, which performed this office better than anything else, was substituted at least once, and sometimes twice, daily. During the night of May i8th, she slept uninterruptedly all night, something she had not done before in many weeks, and she continued to sleep very well thereafter. The next day it was noticed that her limp was diminishing. On May 2ist it was observed that the arteries at the wrist were growing softer and more elastic, and, to dispose of this matter for good, I will say here that when she was discharged at the end of three months, I was unable to observe that any atheroma was left. Finally, in this connection, I will state that a large number of cases of atheroma, at least in vessels susceptible of palpation, respond to body dry hot air treatments in this manner. It is not usual for the condition to disappear so entirely, however. At the end of two weeks she was so far improved that she would be free from pain for twenty-four hours at a time, and could walk a short distance without bringing on a limp. If she continued walking, however, it would provoke the old soreness. I decided to transfer her to the list of out-patients, and she 1 86 Therapeutics of Dry Hot Air. returned to the sanitarium for treatment three times weekly thereafter until August 3, 1900, when I discharged her cured. At this time she had suffered no pain of any description for two weeks. Her progress on the whole had been fairly steady, but there would be periods of two or three days at a time when her pain and disability would return upon her, as is usually the case with these patients. They rarely continue improving steadily from day to day, but have short periods of improvement, fol- lowed by periods of retrogression, but each period of improve- ment reaches a little higher level than its predecessor, until the trouble finally fades gradually and entirely away. I next heard from this patient on February 18, 1901, when she called upon me one afternoon and said that she had felt none of the previous trouble, until about six weeks before, when she had suffered from a severe attack of la grippe. This had been followed by the old familiar pain, which was increasing in intensity, but not in the same place. It now involved the left hip and right elbow, and pigmentation of the skin was present in these regions and about the clavicles. As the initiation of the process was so recent, and she was able to be about, I put her vipon the out-patient list, and she came to the sanitarium for a body treatment, followed by some static modality, three times weekly for the next two months. The treatments were then reduced in frequency to once a week for two months more, when she was discharged cured. The drugs given were the chloride of gold and sodium, arsenic, strychnia, and occasionally a short course of bismuth sub- nitrate and peptenzyme for slight attacks of indigestion. I have kept track of her ever since, and she has not only had no pain or other evidence of her old trouble since her last visit to the sanitarium, but she has never felt better in her life than she has since then. This case is instructive in several ways. First, it is an example of pure, uncomplicated arthritis defor- mans in its very early stages, and exhibits a beautifully typical symptom complex of the affection when it occurs in the hip joint. Second, it shows the futility of anti-rheumatic treatment in uncomplicated cases of the disease. Third, it illustrates during the first attack the power of the :body dry hot air application alone in controlling the disease, as the faradism used acted only, and was intended only, as a sedative. Arthritis Dtformans. 187 Fourth, it exemplifies the power of the body dry hot air treat- ment in lessening, and sometimes apparently removing entirely, atheroma at least of the palpable arterial system. Fifth, it is an example of the influence of acute infectious disease in precipitating a relapse. Sixth, it exhibits the influence of the current from the high tension coil in temporarily alleviating the pains of the disease when other means are inefficient. Usually the static current is the most effective for this purpose, but, as has been pre- viously stated, faradism or the high frequency current gives better results in rare cases. . There is a tendency at the present time to attempt a division of cases of arthritis deformans into two classes ; those exhibit- ing atrophy of the joint structures, and those exhibiting hyper- trophy, as exostoses, etc. This attempt has apparently been engendered by the thought that these two types, if they could be proved to exist, might be differentiable etiologically. The Cases that have so far come under our observation have not led us to believe that such a classification is practicable; many of them exhibit the typical atrophy in some joints and the typical hypertrophy in others during the same attack. The following is a case in point : The patient, a telegraph operator, thirty years old, came under our care for an acute attack of the disease in his shoul- ders, wrists, fingers, knees, and ankles. Twelve years before, when eighteen years old, he had been confined to his bed for several months by the same trouble in his hips, ankles, and toes, from which attack he had recovered. At the time he came under our charge his toe joints pre- sented the characteristic atrophic deformities much exagger- ated, and the pathology of the lesions was interestingly verified later, when he had the little toe of each foot amputated at the metatarso-phalangeal articulation, because these members in their deformed condition interfered with the wearing of shoes. The articular ends of both the phalanx and the metatarsal bone forming this joint were found at the operation to have been absorbed for a distance of one quarter of an inch upon each bone, which accounted for his absolute inability to control the motion of his toes. The point of greatest interest in this connection, however, lies in the fact that both of his hips had been completely anchy- 1 88 Therapeutics of Dry Hot A ir. losed by the first attack ; this fact could only be accounted for upon the hypothesis that the so-called hypertrophic form of the disease had disabled these joints, or that true bony anchylosis had supervened, and true bony anchylosis is said never to develop in this affection. This patient was under treatment eight months before the disease was extinguished from those joints which were acutely involved when he came to us, and no change, of course, took place in the original seats of the process. TREATMENT. It is only within a very few years that systematic efforts to evolve a special therapy for this disease have been attempted, largely because, as already stated, it has been only a few years since our knowledge of the affection has been sufficient to render possible a positive diagnostic differentiation in a large proportion of cases. For this reason text-book literature upon its therapeutics is meager and very unsatisfactory when sub- jected to the test of clinical application, about all that can be gleaned from it being a recommendation to give the patient cod liver oil, iron, or potassium iodide for long periods, to maintain his health in as good condition as possible, and to send him to some hot springs or other health resort. As the belief that in it we have a distinct disease process exhibiting a characteristic symptom complex has gained ground, however, investigation has been directed more and more toward ascertaining what therapeutic measures are logically indicated by its clinical phenomena, and in what degree such deductions as to therapy are confirmed by the actual application of these measures. As a result, evidence is accumulating which indicates that modern therapy is capable of producing curative results in many cases, and marked amelioration of the symptomatology in a large majority of them ; that arthritis deformans is about to be res- cued from the category of hopelessly incurable diseases. We may preface our consideration of the subject of treatment by the flat statement that any measure or remedy that tends, inherently or indirectly, toward repeated or sustained depres- sion of the vitality of the individual is to be unqualifiedly pro- hibited. Local Dry Hot Air Application. As has already been in- Arthritis Deformans. 189 timated, this measure does not constitute an important element in the management of this disease. As it is sometimes fairly efficient in relieving pain, it should always be given a tentative trial when this symptom is troublesome. The technique is that usual to the treatment. General Dry Hot Air Application. The temperature should usually not be less than 350 F ; as atheromatous arteries are commonly met with in these patients, it may be necessary to give less heat during the first two or three treatments until the arteries have softened some, but 350 F. can be attained safely afterward. The guide is found in the circulatory phen- omena, as described in the chapter on " Technique." Sometimes the first treatment cannot last more than fifteen minutes, and the requisite rise in temperature and pulse cannot be attained, but, as the arteries begin to regain their elasticity the response is more and more kindly, until finally the proper amount of influence upon the nerve centers can be induced. The toes of patients with this disease seem particularly liable to suffer from the heat during the treatment, I presume be- cause of inefficiency in the blood circulation, and if the appa- ratus is not so constructed as to permit of the feet being ex- cluded from its interior, it will frequently be found necessary to bring into play all the maneuvers described in the chapter on " Technique " for the relief of the condition. Efficient treatment of these cases will frequently take an hour, but the degree of response which means efficiency must be reached or the patient will not get his due in the way of benefit. The mere induction of perspiration, however profuse, as has been stated on a previous page, does not mean that the treatment has been properly completed. The requisite rise in temperature and pulse-rate does. In this disease, again, it is particularly necessary to apply the higher degrees of treatment intensity and to run the heat up quickly, so as to secure the necessary degree of physiological influence as rapidly as possible. By this method we secure a profound stimulation of physiological function, which is what we desire to effect, whereas, if the patient is treated for long periods with the lower degrees of heat, the ultimate result is 190 Therapeutics of Dry Hot Air. likely to be relaxing, depressing, and pernicious. The distinc- tions drawn between the effects of the different methods of applying heat and dry hot air body treatments in the chapter on " Physiological Action " apply with force in connection with this disease. Additional Remedial Measures. Electricity. The next most useful of the physiological agents is electricity, and the several forms of current have distinct and different spheres of influence. The one of greatest utility is that derived from the static machine, and the wave current and the spark are the most frequently serviceable modalities. Some authors claim to have cured cases with the static current alone, but such an instance has never come within our personal experience, and it is usually difficult enough to benefit these patients materially when all the resources at our command are brought into action. The Static Current. During the acute stage the wave current may be applied to the affected joints twice daily by means of sheet tin electrodes molded to the parts, and this modality is frequently very effective in relieving pain. The in- fluence of every static application is general as well as local, no matter how the treatment is localized, and the effect upon the organism at large is often happy to a degree. The brush discharge from the wooden or carbon electrode applied to the affected part for fifteen or twenty minutes, is effective in relieving the neuralgias as well as the aching pains of the acute condition, in a certain number of cases. Sparks may be applied over the spine and general muscular areas of the body for their tonic effect at any stage of the disease, but, as a rule, they had better not be applied to joints wherein acute symptoms are manifest. When the acute process has subsided, however, and the local phenomena have become confined to soreness and fibrous enlargement, I know of no measure which will so frequently prove effective in removing both as judiciously applied static sparks. Arthritis Deformans. 191, The various neuralgias which accompany the disease are also amenable, as a rule, to the static spark. , The static wave current localized over the solar plexus and abdomen will sometimes give excellent results in the gastric and intestinal indigestions which are frequently quite trouble- some. D' Arson valization. The general application of the high frequency current administered by means of the spiral wire cage of d'Arsonval, or the auto-condensation cushion of Pif- fard, seems to promise much because of its strong tonic ini fluence upon the nervous system and general metabolism, but enough has not yet been done with it in this disease to render possible the formation of reliable conclusions. It has seemed to have exercised a beneficial influence upon some cases in the treatment of which we have used it, enough to encourage us to continue observations upon it in the future. The Continuous Current. This modality, in the form of central galvanization, positive polarity active, negative dispers- ing electrode over the solar plexus, is very helpful in improv- ing the patient's general condition and as a sedative to the nervous system, but I have never been able to secure any local effects with it in this disease upon the joint conditions that I could not have secured just as well, and usually better, with something else, whether the current volume was weak ( 5 ma.') or strong (75 ma.), except in muscular spasm due to nerve irritation; in the torticollis of arthritis deformans the contin- uous current, in doses of from 5 to 20 ma. for fifteen minutes, will sometimes give more satisfaction than anything else as regards relief of both pain and spasm. In applying central galvanization, the brain is treated first, and it should be remembered that great care must be exercised when using this current upon this region of the body. Be- ginning with the current at zero, it should be increased gradu- ally, diminishing the volume immediately if dizziness, faintness, or nausea occurs ; it is very easy to throw a patient into syncope during this operation. Usually from 3 to 5 milliamperes for three or four minutes will be enough. In the cervical region the milliamperage may be increased to from 5 to 15, according to 192 Therapeutics of Dry Hot Air. the patient's tolerance, for five minutes. The dorsal and lumbar regions may be treated for five minutes each, and, as no danger- ous symptoms are to be feared in these vicinities, the current volume may be increased until the cutaneous sensibilities revolt, which occurs ordinarily at from 20 to 30 milliamperes. It has been stated that the soreness in the joints may be re- lieved by treating them with weak galvanic currents, positive polarity, using a hot-water bath in which the affected members are immersed as the active electrode. Although we have tried this repeatedly, we have never been able to convince ourselves that any more benefit resulted than would be produced by the hot water alone without the current, and in acute cases the suffering has occasionally been increased apparently. It is un- questionably greatly inferior to the static modalities, faradism, and dry hot air in this situation. Magnetic-Induced Current. This current plays very little part in the treatment of arthritis deformans when a static machine is available, but when it is not, a good high tension coil is very useful as a temporary sedative. The current is passed directly through the aching joints with a strength as great as is consistent with the patient's comfort, and the relative positions of the polarities is usually a matter of indifference. In the form of spinal and general faradization, it exercises a very helpful influence upon the deep nerve centers and general metabolism. In rare cases it will be found that the coil gives sedative results in this disease superior to those pro- duced by the static modalities or dry hot air. It may be applied as often as pain demands it without injury to the patient. Mechanical Vibratory Stimulation. This remedial agent has not yet been used extensively enough to justify the forma- tion of an opinion as to its curative powers in the treatment of this affection. It is undoubtedly, however, a powerful general tonic ; it will relieve the pain of muscular spasm and relax the spasm more effectively than any other measure with which I am acquainted except anaesthesia, and it is powerfully and harmlessly sedative to the irritable nervous system ; in all of these capacities it enters logically into the management of ar- Arthritis Deformans. 193 thritis deformans, and will be found practically of decided value and assistance. Massage. Massage, either general or local, will very rarely have to be considered in the treatment of this affection when the agencies already mentioned are available. When they are not, however, it will be found useful in relieving pain, locally, and in improving the patient's condition generally. Diet. The widespread impression that gout and rheumatism were largely concerned in the etiology of the disease is respon- sible for the common practice of denying these patients red meats, and sometimes all meats. We believe that this restric- tion is not only unnecessary usually, but that it frequently in- flicts positive harm upon the patient. Malnutrition is an almost constant characteristic of this disease, and the more nourishing and generous the diet, within reasonable limits, the more will the progress towards recovery be facilitated. These dietary limits are represented by the capacity of the individual patient for digesting and assimilating his food, and must be defined, as regards both quantity and variety, by this capacity as ascertained in each individual case. It has been our experience that, as a rule, meats of all kinds except pork are well digested and assimilated by these patients, and are bene- ficial, and that restriction is much more frequently required with reference to the starches and sugars. Intestinal indiges- tion demands attention in these cases with a moderate degree of frequency. Clothing. In any disease exhibiting more or less constant pain as a symptom, a good quality of woolen underclothing, of light weight in the summer and moderately heavy in the winter, is a source of comfort to the patient in protecting the skin from sudden changes of temperature, which are liable to increase the pain; arthritis deformans is no exception to the rule. Protection of the skin by woolen undergarments renders another service by maintaining the function of this emunctory, which is so important a factor in the general bodily metabolism. Impairment of general metabolism is usually a prominent feature of this disorder. 194 Therapeutics of Dry Hot Air. Drugs. The drug treatment of uncomplicated arthritis deformans confines itself within very narrow limits, and is unsatisfactory in the extreme, as far as the obtaining of curative results is concerned. The internal administration of medicines is indi- cated for two purposes; to favorably influence the course of the primary disease process, and to mitigate the symptoms. Alteratives and Tonics. Only a very few elements of the materia medica have succeeded in gaining a lasting reputation in this connection, and all of those that have, except the salicy- lates, are of the " Tonic " and " Alterative " classes, hence exert their beneficial influence through their power to improve the general metabolic functions. Prominent among these may be mentioned the iodide of iron, cod liver oil, the hypophos- phites, arsenic in its various combinations, strychnia, the chlo- ride of gold and sodium, and potassium iodide. The first mentioned has given us the best results, improve- ment usually manifesting itself, when it obtains at all, in about three weeks after the commencement of its administration. It should be given for periods of from three to six weeks, with intermissions of two or three weeks. Cod liver oil does good service in those cases characterized by emaciation, if well borne by the stomach. Arsenic and strychnia are fairly useful in many instances as general tonics. The chloride of gold and sodium and potassium iodide or hydriodic acid sometimes seem to render considerable service, but they fail to influence the disease in such a large proportion of cases that their efficiency is not nearly as great as is generally supposed. Quinine has been lauded as a remedy for arthritis deformans, but we have never been able to convince ourselves that it was of any service in any of the cases to which we have adminis- tered it, and regard its claim to efficiency in the management of this disease, per se, as open to grave doubt. The Salicylates. The relation of the salicylates to this disease deserves a special mention, as they sometimes render Arthritis Deformans. 195 excellent service in relieving pain and swelling. Although it is improbable that rheumatism is an etiological factor in any considerable number of cases, yet it is not so very uncommon to see an attack of rheumatism engrafted upon an already existent arthritis deformans, and, as the salicylates fail absolutely in so many manifestly uncomplicated cases, it seems reasonable to consider that many of those in which they are useful are in- stances of such a complication. The fact that beneficial in- fluence is obtainable by their use only up to a certain point would favor this view. The difficulty of making a positive diagnosis of rheumatic invasion under such circumstances is, in many cases, of course, insuperable. Whatever the explana- tion, the fact remains that the salicylates, especially aspirin, are sometimes very helpful in relieving painful joint conditions occurring during the course of arthritis deformans. Laxatives. Constipation is sometimes present in a degree to demand attention, and the various mineral waters, sodium phos- phate, magnesium sulphate, the aloin, strychnia, and belladonna mixture, or compound licorice powder, will be found helpful. What particular one should be used must be determined by the tolerance of the individual patient. Digestants. Digestive disorders can generally be controlled by regulating the diet, but the digestive ferments, carminatives, charcoal, bismuth subnitrate, and strychnia will sometimes have to be called upon to assist in this work. Pain-Relieving Agents. The constant harassing pain is one of the most troublesome symptoms of the disease as far as management is concerned. Most of these patients have become so habituated to pain that they bear a moderate amount without much complaint, but sometimes severe exacerbations, lasting for several hours, days, or weeks, will occur which demand atten- tion. Opium, or any of its derivatives, is inadvisable because of the chronic character of the trouble, because it loses its influence in a very few days unless given in increasing doses, and because of its evil effects upon the system at large. We have occasionally given coal tar derivatives when the paroxysms were very severe, but they also produce undesirable effects upon the metabolic and circulatory functions when continu- 196 Therapeutics of Dry Hot Air. ously administered in effective doses for any length of time. None of the ordinary pain-relieving drugs are of much service in controlling this symptom, with the exception of the salicy- lates, as hereinbefore mentioned. Much relief, however, can usually be obtained by the use of external applications, and baume analgesique (Bengue), the tincture of iodine externally, and the various anodyne lotions have given us better results than anything else. The hot water bag, or in some cases, the ice-cap, is very useful in this connec- tion, but when the latter is used the effect should be closely watched, as it will occasionally precipitate severe neuralgias if applied too long. Management of Affected Joints. During the acute stages the joints involved should be kept at rest; I do not mean such complete rest as would necessitate enclosing the member in a splint, but the patient should be directed not to use the joint to such a degree as to produce pain. Patients are sometimes urged to force the joints to functionate no matter how exquisite the anguish induced, and the effect is usually to increase the local pathology already present, to say nothing of the evil influence upon the general nervous system ; nothing is more depressing than severe and long-continued pain. These remarks also apply to passive movements. After the acute process has subsided, judiciously- regulated, gradually-increased movements of the stiffened joints, both active and passive, are beneficial, and frequently partial anchy- losis can be entirely removed thereby, but the sudden forcible breaking down of the anchylosis of arthritis deformans, when it exists to any great degree, is a procedure which we have never seen followed by anything but evil results in the way of increased and usually entirely hopeless anchylosis, and in men- tioning the procedure I desire to express my conviction that it should be expunged from the therapeutical category of this disease. Routine Treatment. Although dry hot air alone will cure some cases of ar- thritis deformans, yet, as I have already said, it is sufficiently Arthritis Deformans. 197 difficult to benefit the majority of these patients materially, even when we use all the resources at our command ; this im- plies the desirability of giving them the benefit of everything that is known to exhibit helpful properties, and brings up the question, "What are the most advantageous combinations?" That which has given us the most satisfaction as a routine treatment, to be modified according to the conditions surround- ing the individual cases, is as follows: 1. A diet as generous as can be digested and assimilated by the individual case, and consisting largely of red meats. 2. Rest in bed for at least twelve hours out of the twenty- four. 3. A pill consisting of 1-40 of a grain of strychnia sulphate, and i 1-2 grains of ferrous iodid three times daily half an hour before meals, and in the emaciated cases one to four drams of cod liver oil three times daily after meals. 4. A dose of some one of the mineral waters or sodium phos- phate before breakfast, every two or three days, if constipa- tion is present. 5. A body dry hot air treatment two or three times weekly. 6. Central galvanization once or twice weekly. 7. A general application of mechanical vibratory stimulation two or three times weekly. 8. A static electrical application at least once every day, consisting in acute cases of the Morton wave current localized over the affected joints or spine, and in the chronic cases of long, thick sparks to the affected joints one day, and the Morton wave current localized over these joints the next. In some cases some one of the high frequency currents applied either locally or generally may advantageously replace sortie of these static applications or be added to them. 9. With anchylosed joints, wherein the acute condition has subsided and the functional impairment is not due to osteophyte formation (and in our experience it has not frequently been due to this condition), passive movements every day, in the form of alternate forced flexion and extension, the attempt being made to increase the excursion of the manipulated mem- ber each time, are of considerable use. The movements should 198 Therapeutics of Dry Hot Air. not be violent enough to produce sudden breaking down of the offending tissue, or to cause the patient much pain, otherwise the original pathological process is very likely to be re-awak- ened and the last condition of the victim will be worse than the first. The effects of these movements should be carefully watched, as this same evil result will follow if they are com- menced too early. The advantages contingent upon temporary suspension of treatment, which were suggested in the section upon " Inter- missions in Treatment," Chapter III., are sometimes very noticeable in arthritis deformans. Our custom is to keep the patient at the sanitarium for six or eight weeks, or until he has improved substantially, for the first course, and then send him away for a month ; he then returns to the sanitarium for three or four weeks more, after which he is recommended to go away again. The time duration of the courses of active treat- ment, and of the intervals between them, will, of course, have to be governed by the conditions surrounding the individual cases as regards the degree of improvement attained, etc. RELAPSES. Cases of arthritis deformans are very apt to relapse during the first year after recovery. A very common cause is an attack of some acute disease of a debilitating nature, as la grippe ; another is that patients who have been accustomed to an active life before the disease disabled them are so elated and confident at being again in condition to do something after months, and sometimes years, of enforced idleness, that they overwork. The overstrained nerve centers yield as they did before, and another outbreak obtains. In fact, anything tend- ing to lower the general vitality is liable to result in a reappear- ance. It may involve the same old joints, or entirely new ones may be invaded, and those affected previously escape alto- gether. The victims should be gotten under thorough treatment again as soon as possible, and this should be persevered in until recovery supervenes. Under the very best of conditions re- covery is a matter of months, but when we reflect that in the Arthritis Deformans. 199 past we have been able to accomplish scarcely anything with any degree of certainty in any length of time, the possession of measures which will restore to some of these victims useful joints and comfort in living is a matter upon which we may most sincerely congratulate ourselves and our patients, however long it takes to do it. Perseverance is a grand omniscient word in the treatment of this affection. CHAPTER X. PERITONITIS; PLEURITIS; SYNOVITIS; NEURITIS AND SCIATICA; LITH^MIA AND GOUT; NEU- RALGIA AND MYALGIA; VARICOSE ULCERS; OTITIS. In the preceding chapters the different phases of the physio- logical action and clinical results of dry hot air applications have been discussed and illustrated with sufficient thoroughness to render apparent what effects may be expected to follow their use in most of the pathological conditions commonly encoun- tered, and how these effects are produced. In the affections which remain to be considered, therefore, the subject will need to be treated but briefly. PERITONITIS. Varieties. This disease is usually secondary to some other affection, as benign or malignant tumors, salpingitis, appendi- citis, etc. It is also caused by tuberculous infection of the peri- toneum, sometimes apparently by microbic invasion from the intestinal canal, and occasionally an instance is encountered during the course of, and seemingly traceable to the specific etiological factor pertaining to, an infectious fever. Sphere of Usefulness of Dry Hot Air. When peritoneal inflammation is microbic in causation and confined to the membrane itself, it will usually yield kindly, rapidly, and per- manently to dry hot air; the condition, under these circum- stances, may be likened to local septic infection, as far as thermotherapy is concerned. When it is secondary to some other condition, however, permanent cure will necessitate eradi- cation of the exciting cause. When this cause is a benign neoplasm, operative interference must be considered ; if the growth is malignant, operation or X-ray exposures, or both in many cases ; if a deep, localized septic process, as appendicitis Per it on it is. 20 1 for instance, operation must always be considered early and earnestly. One of the most prominent and harassing symptoms accom- panying nearly all forms of peritoneal inflammation, except that due to the tubercle bacillus, is pain. Dry hot air will al- ways relieve completely that proportion of it which is caused by the peritonitis proper, and, as this remedy may be applied as often as the pain recurs, the patient's comfort may be main- tained indefinitely. In salpingitis coming under treatment moderately early and before suppuration has been established, the knife will rarely "be needed for obtaining control of the condition. The body , treatment two or three times a week, in combination with the local once or twice daily, will usually effect a rapid and com- plete subsidence of the pathological process, and the writer has seen several cases recover under the local application alone. The body treatment, however, always hastens the result, and in some cases its use is imperative. The deeply-seated aches and pains due to the salpingitis itself are controlled by the body treatment more effectually than by the local application in many cases. The writer has never had the courage to rely upon the ther- mal agent alone for the cure of appendicitis, but Burwash of Chicago reports two cases which he carried to a successful ter- mination with this measure only. It seems to me, however, that in view of the ever present difficulty, if not impossibility, of differentiating clinically those cases of appendicitis which are due to impaction of a foreign body from those which are caused purely by germ infection, we should not feel justified in aban- doning early operation for the treatment by dry hot air. If all cases were of the latter etiological type, thermal applications would undoubtedly prove curative in the vast majority of in- stances, but they could not, and should not, be relied upon exclusively in the former. This agent is very effective in limit- ing inflammatory processes, and, as repair of wounds and abscess cavities is always greatly hastened by its use, it may be applied while waiting for operation if pain is troublesome or when the patient is sufficiently ill-advised to refuse operation. COLLlElilE t- u \ s i e i 2O2 Therapeutics of Dry Hot A ir, In tuberculous peritonitis, the occasional splendid results which have followed a simple laparotomy give ground for the belief that this agent may prove to be of benefit here. The most probable explanation of the way in which laparotomy has accomplished its' effects seems to be that the absorptive power of the peritoneum, which is enormous under normal conditions, is rescued from a temporary inhibition, which has resulted in so impairing the physiological resistance .of the membrane as to allow pathogenic germs to gain a lodgment and prolifer- ate, by the operation ; that the congestion due to allowing the air or irrigating fluids to come in contact with the membranes, so influences their function as to bring about the encapsula- tion and ultimate phagocytic destruction of the invading micro-organisms. Dry hot air possesses the power of inducing physiological congestion, hence restoration of impaired ab- sorptive function, to a degree unapproached by that of any other measure now known, and if this is the true explanation of the effect of laparotomy, the thermal agent should be valu- able in this affection. The influence of the body dry hot air application in eliminat- ing general toxaemia and stimulating the general physiological resistance, is as marked in this disease as elsewhere, is always of great assistance in securing a favorable termination, and in many cases constitutes the measure most to be relied upon. Illustrative Case. It was the results following its employment in a case of acute peritonitis that first suggested to the mind of the writer that dry hot air might be useful in pathological conditions other than rheumatic ailments and traumatic joint affections. The case was reported in the New York Medical Journal in 1899, and is such a striking illustration of the splendid results sometimes obtained by the use of thermo-therapy in this disease that I quote it from that periodical as follows: " Miss L. L., waitress. Was called to see the patient at 2 o'clock A. M., November 8, 1898, and found her suffering with severe colic. She had been feeling poorly and suffering from slight cramps in the bowels for a week past. Abdomen was j JJG 'i ?. c j Peritonitis. 203 tense and tender, this last being especially marked in the left iliac fossa. Bowels had been constipated during the preceding week. Pulse, 72 ; temperature per mouth, 98.6 F. I made a provisional diagnosis of colic from indigestion and constipation, but as patient was living in illicit relation with a man about town and as I had previously met with some trying surprises in the way of abdominal inflammations during my practice, I de- cided to call again and watch her progress. I administered morphine, a quarter of a grain, and ordered magnesium sul- phate in teaspoonful doses hourly, to be begun in the morning and taken until bowels moved, then discontinued. Patient was comfortable, so far as pain was concerned, in half an hour, and I returned to my couch and resumed my interrupted slumbers, " Same day, 6 P. M. Found patient suffering acutely from severe cutting pains all over the abdomen ; pulse 106, tempera- ture 100.5 F- Abdomen tense, acutely sensitive to touch, but focus of tenderness still remained in left iliac fossa which region was entirely intolerant of manipulation. I was unable to find anything specific in the neighborhood of the appendix, changed my diagnosis to gonorrheal salpingitis and peritonitis, and was glad that I had called again. Morphine had controlled pain pretty well for four hours, after which it returned and continued with increasing intensity up to the time of my visit. Magnesium sulphate had produced two small thin movements, accompanied by sharp pains. I made up my mind that I was in for another of the harassing experiences which go to make up the ordinary management of these cases, ordered that flannels wrung out of hot water be constantly applied to the abdomen as hot as could be borne by the patient, gave her another hypodermic, left her two quarter-grain morphine pills to be taken in case the pain became unbearable before my next visit, and put her on an exclusive milk diet. " November 9, 12 M. Patient had been suffering intensely since midnight. Knees were drawn up, abdomen much dis- tended, unable to make the least movement without provoking excruciating agony, which was also occasionally exacerbated by attacks of retching which accomplished nothing; she was shiv- ering and her teeth were chattering from the exhaustion due to long-continued suffering. Pulse 104; respiration 28, very shallow and quick; temperature 101.2 F. The morphine pills that I had left at my previous visit had not been used, as I had requested her not to take them unless it was absolutely neces- sary. With the proverbial capacity of her sex for enduring pain, she had not considered that the point of absolute necessity had yet been reached. I realized that something must be done, but I hated to inaugurate a systematic course of morphine with 2O4 Therapeutics of Dry Hot Air. its resultant evils, particularly undesirable in a disease of microbic origin where it is of the first importance to preserve the metabolic activities of the body unimpaired ; as the hot applications were doing no good, however, it seemed the only measure capable of dealing with the situation. " While I was considering, the attendant came to the bedside to renew the hot application. The patient looked up at her and exclaimed, ' Oh, is it very hot ? ' Upon being assured that it was, she remarked, ' The hotter you get it the better it feels.' " Like a flash my dry hot air apparatus rushed into my mind. With it I could apply a heat of 500 F., whereas the flannels could not be used at more than 160 F. I asked her if it was true that the greater the heat the greater the comfort she ex- perienced. She answered that if the flannels were not very hot they gave her no relief at all. A small ray that was hardly strong enough to be hope brightened the darkness. If 160 F. of heat gave her some relief from pain twice or three times that might give her a good deal, and by frequent repetitions I might be able to avoid the morphine. The prospect was worth the experiment. I told her that I would try something else in the afternoon, and did not administer any morphine. " At 4.30 P. M. I applied dry hot air locally over the abdomen with doubt, fear and trembling. My gratification can better be imagined than described when, at the end of ten minutes, the sufferer's face relaxed its pain-distorted lineaments. In thirty minutes she looked up at me with a quiet smile, saying, ' Oh, how good that feels ! ' and in forty-five minutes, while still under treatment, she had fallen exhaustedly asleep for the first time in thirty-six hours. " At the conclusion of the treatment the patient expressed herself as being entirely free from pain while she kept still, but when she moved it was still there, and manipulation was as little tolerated as before. I left the apparatus there, directed that I be called immediately when pain returned, and departed walking upon air because of the result achieved. I expected, of course, that a repetition would soon be necessary. However, I had been able to give her a relief so perfect that even mor- phine would have been inadequate for its accomplishment, and by withholding the drug had been able to preserve her mental and physical functions unimpaired. If I could keep this up I would be willing to treat her every hour, if necessary. The hours wore on, and to my growing astonishment I received no summons until, by the following morning, I began to fear that another physician had been substituted for me without the for- mality of my discharge having been observed. I found it diffi- Peritonitis, 205 cult of belief that the treatment could have produced results so happy and so long continued. " loth, 12 M. Patient greeted me smilingly, reporting that relief from pain had continued complete until nine o'clock the preceding evening, when, for about fifteen minutes, she suffered from slight cramps. At midnight she had severe cramps for an hour, but none since, and to make a long story short, I will say here that those were the last pains she suffered. The abdomen was relieved of its distention ; tenderness upon pressure had entirely disappeared from the right abdomen, but was con- siderably in evidence in the left, and very much so in the um- bilical region and below, from manipulation of which area she shrank in terror. Bowels had functionated spontaneously and with little pain; was taking milk freely and stomach was not at all irritable. Pulse 72; respiration 18; temperature 98.6 F, Dry hot air was again administered. " Same day, 6 P. M. Patient was and had been entirely com- fortable. Pulse 83 ; respiration 18 ; temperature 99 F. Di- rected that I be called again if pain recurred, and did not see her again until the next day. " nth, 10 A. M. Patient had slept uninterruptedly all night and was feeling hungry. No tenderness was present anywhere in the abdomen except over a small area immediately inferior to the umbilicus. Pulse 72; respiration 16; temperature 98.6 F. Dry hot air administered. " Same day, 9 P. M. Patient had been sleeping some during the day, was entirely comfortable and complained of only very slight tenderness on pressure in umbilical region. Pulse 66; respiration 18; temperature 98.6 F. " I2th, 8 P. M. Found patient sitting up, dressed, sewing. No pain or tenderness upon pressure was anywhere discover- able. Pulse 76; respiration 18; temperature 98.6 F. " 1 5th, 8 P. M. Patient called at my office by appointment. Pulse 78; respiration 20; temperature 98.6 F. Examination revealed slight tenderness upon deep pressure over left Fal- lopian tube; nowhere else. Once more administered dry hot air and requested that she report in three days. " i8th. Reports that she returned to her work yesterday morning. Feels as well as she ever did in her life, and search- ing examination betrays absolutely no sign of her late illness. She wrote me a letter from another city two months later, stating that she was, and had been, perfectly well since I last saw her." 2o6 Therapeutics of Dry Hot A ir. Treatment. Local Dry Hot Air Application. The patient should be prepared as described in the chapter upon " Technique " for the abdominal application, the apparatus connected and the heat turned on; in fifteen or twenty minutes the patient will be free from pain. The application should last an hour when it is possible to maintain jt that long without the induction of undue fatigue, and the temperature should be raised to from 350 to 400 F. When the application is finished the patient is merely made comfortable again in bed, no special after- treatment of the abdomen being required. The treatment may be repeated as often as the pain returns, but should be applied twice daily anyway for the first four days, however comfort- able the patient may be. General Dry Hot Air Application. The technique of the body treatment in this disease does not differ from that usual in this procedure. As the body temperature is usually consid- erably above normal when the patient enters the apparatus, it cannot always be relied upon as a guide to the duration of the seance or the intensity of the heat ; the pulse acceleration and the general effect upon the nervous system must govern. As a rule the treatment should last about half an hour, and the pulse should be accelerated to 125 or 130 beats per minute. It is ordinarily not wise to push it beyond 140 beats per minute, and the phenomena indicating over-stimulation should not be induced. The frequency of administration is governed by the response on the part of the patient. It will usually be well to apply the measure every other day during the first week, after which the interval may be lengthened. Additional Remedial Measures. Aside from the ordinary care of the alimentary canal, inci- dent to this affection, surgical measures constitute the only means additional to thermo-therapy that will have to be con- sidered in the treatment of peritonitis. When the exciting cause is salpingitis, long-continued intra- Pleuritis. 2 1 1 vaginal applications of the rapidly-interrupted current from the long, fine-wire faradic coil through the bipolar electrode, will sometimes give temporary relief from pain, but the writer has not infrequently seen suffering increased for several hours thereby; its use therefore is not to be unqualifiedly recom- mended in all cases. The internal administration of drugs for the relief of pain is almost never called for, and drug stimulation is entirely superfluous when a body apparatus is at hand and usually when the local treatment is employed alone. The advantages dependent upon the employment of this agent in peritonitis, viz., rapid relief of pain, restoration of absorptive function to the membranes, etc., have been suffi- ciently dwelt upon to warrant omission of further mention, and anyone who has carried a patient through an attack under ordinary management will be in a position to readily appreciate the value of the service it renders. PLEURITIS. Varieties. Of the pleurisies it may be said, as of perito- nitis, that they are usually secondary to some other affection, as pneumonia, pulmonary tuberculosis, malignant disease, etc., and as in peritonitis also, it is evident that the permanent cure of secondary pleurisies will necessarily involve removal of the exciting cause. There is another class of pleural inflammations, however, which seem to originate in the membranes themselves primarily, and which are at times most refractory. They are accompanied by effusion into the pleural cavity and may be divided for thermo-therapeutical purposes into two classes, viz., those in which the effusion is serous or fibrinous hydrothorax and " dry pleurisy " respectively and those in which the exu- date consists of pus. Sphere of Usefulness of Dry Hot Air. The pleurisies accompanying pneumonia, as we have seen, and pulmonary tuberculosis, as we shall see later, yield rapidly to dry hot air applications, both as regards their symptomatology and intrinsic pathology. Enough cases of hydrothorax and " dry pleurisy " have also 212 Therapeutics of Dry Hot A tr. been treated to demonstrate that this agent is capable of ren- dering valuable assistance here ; that aspiration will have to be done less frequently under such management, and that when it is done the return of the pleural membranes to normal structure and function will be quicker and more frequent than it is at present. A very convincing case was reported by Burwash in the Chicago Medical Recorder for December, 1901. The diag- nosis indicated by the physical signs was confirmed by with- drawing some of the fluid through an exploring needle, and the patient was ill but four weeks from the inception of the attack to its termination. The effusion was extensive enough at one time to produce dyspnoea and interference with the heart action. The local application only was used and diuretics and strychnia were administered in combination therewith. The treatment of pyothorax, however, is, always has been, and of course always must be, operative interference ; but many cases refuse to recover even when resection has been done, and there is reason to believe that dry hot air is capable of reducing the number of these incurables and of greatly hastening recov- ery in all post-operative cases. As these patients are usually debilitated subjects, it is always wise and sometimes necessary to invoke the influence of the body treatment upon general metabolism, as well as the direct effect of the local application upon the pleurae. Treatment. Local Dry Hot Air Application. The local treatment should be used twice daily for an hour at from 350 to 400 F., until improvement is manifest, and once daily thereafter, until recovery is complete. The preparation of the patient and the technique are the same as have already been described in the section on pneumonia. General Dry Hot Air Application. The body treatment should be applied two or three times weekly according to the effect upon the patient's general condition, and the technique is that usual to this procedure. As the bodily temperature is not ordinarily much elevated in this affection its fluctuation during the seance will usually be of value in determining Synovitis. 213 the length of the treatment and the intensity of the heat required. Additional Remedial Measures. The other methods of physical therapeusis are rarely of value in pleuritis, and the dietary, drug, and surgical manage- ment of the disease do not differ from those commonly inci- dent to the affection, except that anodynes and stimulants are very rarely called for when dry hot air is attainable. SYNOVITIS. Varieties. The vast majority of synovial inflammations are due to one of four etiological factors, viz., trauma, rheumatism, gonorrhea, or tuberculosis. The writer's experience with dry hot air in this affection has been confined principally to cases owning the three first-mentioned causes, and it has been emi- nently satisfactory. Sphere of Usefulness of Dry Hot Air. It is hardly neces- sary to state that a case of synovitis of any sort should be gotten under treatment as early as possible. If the traumatic form is attacked by dry hot air within three or four days after the injury has been sustained, the pain will be relieved at once and the case will ordinarily reach a successful termination within three weeks. I have never seen one last over six weeks even when ten days had elapsed since the injury, and Corwin has reported one case of acute synovitis of the knee in a boy fifteen years old, exciting cause not stated, which recovered completely with but two treatments. It is the writer's belief, however, that such a rapid response is very rare, and he has personally never seen a case of true synovitis, whatever the etiology, recover in such a short time, however early it came under treatment. In the rheumatic variety, on the other hand, rapid response is the rule when appropriate medication accompanies the dry hot air; the pain is relieved at once, and recoveries with but four or five applications are not at all uncommon. In gonorrheal synovitis it is, of course, essential that treat- ment be directed against the primary focus of infection as well 214 Therapeutics of Dry Hot Air. as the joint mischief, but the use of dry hot air on the joint affected will greatly hasten the recovery and anchylosis will usually be avoided thereby. This is one of the situations wherein the agent cannot invariably be relied upon to effect immediate relief. of pain; it sometimes makes it worse for several hours afterward. The ultimate result attainable justi- fies its application even under these circumstances, however, unless the pain is exacerbated to an unendurable degree. Tuberculous synovitis is the most resistant of the varieties to this as to all other methods of therapeusis. A cure requires from two to six months, but in the majority of the cases so far reported the joints have eventually been restored to useful function, and that without operative interference. If surgery has finally to be called upon the prospect of ultimate cure is greatly increased if dry hot air has been applied, because of the improvement in the local nutrition effected by this measure. Walton has reported most excellent results in tuberculous synovitis, and although our experience has been slight, yet it has encouraged us to undertake further investigation. One case in particular responded most happily. The patient, a boy seventeen years old, had been afflicted with tuberculous disease of the knee-joint for several years and for the preceding four years had been under the most approved treatment. He came to the sanitarium with the leg in a splint and the joint anchy- losed. A course of local and general dry hot air applications, extending over a period of five months, restored seventy-five per cent, of the normal motion to the joint, enabled him to dis- pense entirely with the splint, stopped his daily temperature elevations and night-sweats, increased his body weight, and, in short, brought about a condition of normal health. Near the close of the course of treatments this patient was exhibited by the writer before the Clinical Society of the New York School of Physical Therapeutics. It is probable that dry hot air produces its beneficial results in joint tuberculosis by improving the nutrition and increasing the cell vitality of the part, rather than by a directly fatal influ- ence upon the bacillus itself, as has been suggested. If the germ were directly destroyed by the heat, the recovery would Synovitis. 215 be immediate, whereas it is in fact always found to be more or less slow. It has been said that dry hot air is contra-indicated in joint tuberculosis, but as this statement is not warranted by the pathology of the condition, the physiological action of the agent, or actual clinical experience, it may be dismissed from further consideration. Treatment. The knee is the joint most frequently affected in synovitis and the local treatment the one most frequently indicated. Local Dry Hot Air Application. The apparatus designed especially for this joint would seem to be the one most likely to be useful in this situation, but for the reasons stated in Chapter III. the general local apparatus will give better results when the joint is susceptible of sufficient extension to permit of its use. The technique appropriate to the special knee apparatus is fully described in Chapter III., in the section that treats of this machine. When the general local apparatus is used the wrapping should be started at the toes, and the whole of the limb, from the toes to a point a little above the middle of the thigh, invested in three thicknesses of the toweling. The limb is then placed in the apparatus, the limiting attachment fastened around the middle of the thigh, and the heat run up to about 400 F. Whichever apparatus is used, the treatment is continued for an hour and administered twice daily, or oftener if the pain be- comes troublesome. After-Care. In the traumatic variety, after the application has been completed, it is wise to wrap an elastic bandage about the joint just tightly enough to produce a slight, even pressure, and this should remain in place until the next treatment. In rheumatic synovitis no compression or immobilization device is called for. It is desirable only that the patient refrain from moving the part, and this he will ordinarily do of his own volition. When the exciting cause is gonorrheal infection, the persist- ent pressure of an elastic bandage can rarely be borne, but it 216 Therapeutics of Dry Hot Air. is advisable to secure immobility of the joint by applying a splint or some retaining apparatus until the acute inflammatory process has subsided. Passive motion may then be employed immediately after each treatment. Whether or -riot immobilization shall be applied in tuber- culous synovitis must be determined, of course, by the condi- tions obtaining in the individual case. General Dry Hot Air Application. The body treatment is always extremely helpful in synovitis of any sort, but it is rarely imperatively indicated in cases due to trauma or rheuma- tism ; in gonorrheal cases, however, recovery is always mark- edly hastened by its employment, and frequently a satisfactory result cannot be attained without it. We have here a condition comparable in many respects with that obtaining in local septic infection, and the technique of the application here is the same as that described for septic infection. Much the same may also be said of tuberculous synovitis, in which disease the writer is of the opinion that the body treat- ment should always be employed. We have here, not only a localized process, but an impairment of the vital functions gen- erally and, as we have seen, no measure is more effectual in combating a general debility than the judiciously-administered general dry hot air application. Additional Remedial Measures. Electricity, in the form of the Morton static wave current, the static spark, or galvanism, is very useful in traumatic and rheumatic synovitis, the efficiency of the modalities being in the order in which they are named. The high frequency current has been used considerably abroad in all varieties of synovitis and good results reported, but dry hot air, alone, or in combina- tion with one or more of the above-mentioned agents, will ordi- narily give results which leave little to be desired when the lesion is due to trauma or rheumatism. The Morton wave current or the brush discharge will some- times give good results in relieving the pain of the gonorrheal variety, but operative interference constitutes the most impor- tant curative adjunct to be considered in this condition. Neuritis. 217 In tuberculous joint inflammation the latest therapeutical development is the X-ray, and this agent has produced most excellent curative results in some cases of this affection. It may be administered in conjunction with dry hot air without necessitating any modification of the usual technique pertaining to either agent. The dietary and general management of a case of synovitis that is being treated by thermo-therapy does not differ from that ordinarily indicated, except in the greatly-lessened fre- quency with which pain-relieving drugs are required. NEURITIS. Etiology. This affection is another of those owning a varied causation. Prominent among its causes are excessive use of certain sets of muscles and nerves, which is exemplified by the brachial neuritis sometimes encountered among pen- men; the presence of abnormal substances in the blood, illus- trated by the neuritis of alcoholism, plumbism, and the infec- tious fevers ; and traumatism. Lithaemia and other constitu- tional aberrations are also met with among its causative phe- nomena, and there can be no doubt that sudden chilling of the body under certain conditions will inaugurate an attack, al- though the manner in which it does so is not entirely clear. A neuralgia so induced would not be difficult to understand, but in the case of a true neuritis it would seem as if something else must also be etiologically involved, and it is probably through an inhibitory influence of cold upon general metabo- lism, whereby abnormal and irritating products are developed in the circulation, that the attack is provoked. Treatment. It will readily be appreciated that removal of the exciting cause is a necessary factor in the attainment of a cure. Dry Hot Air. The use of this agent in neuritis is, on the whole, somewhat disappointing. The local application will nearly always relieve the pain for a time, but it almost invari- ably returns after a little as badly as ever, and I have never been able to convince myself that it possessed much, if any, 2 1 8 Therapeutics of Dry Hot A ir. value as a curative agent. The body treatment is more useful, however, and especially in those cases dependent upon consti- tutional causes it is fairly efficient. Even at the best, however, dry hot air alone is not a very reliable measure. Additional Remedial Measures. Electricity. The best results are obtainable with the elec- trical currents in combination with thermal applications, and my routine treatment is to apply the body treatment two or three times weekly and some electrical modality twice daily, except on the dry hot air days, when one electrical treatment is omitted. The local application of heat is used ad libitum when the pain is troublesome, in those cases wherein experience dem- onstrates its value. The electrical modalities used are the static wave current, the brush discharge and spray in recent cases, and sparks and weak galvanic currents in chronic cases. Some authorities do not countenance the use of galvanism in neuritis, and in many cases it will unquestionably make the trouble worse. In other patients, however, currents of from three to ten milliamperes will just as unquestionably produce beneficial results, and if a case is not doing well under other measures I believe that it should be cautiously tried. The rapidly-interrupted current from the long, fine-wire coil is excellent for sedation, but I have never observed that it exercised much, if any, curative influence in true cases of this disease. Diet. The regulation of the ingesta will depend upon the conditions obtaining in the individual case as regards idiosyn- crasy, and whether or not constitutional and diathetic factors are involved in the etiology. Drugs. Medicines are not efficient against a neuritis, />