CLIMATO-THERAPY, HYDRO-THERAPY, ETC
CLIMATE AND RESIDENCE
While, naturally, individuals display wide differences in their capacity
of adjustment to variations in climate and season, there is no doubt
that the gouty, as a class, are abnormally deficient in their power of
adaptation in this respect. Said Hippocrates in one of his aphorisms,
“Podagrici affectus vere et autumno plerumque moventur,” and this
peculiar influence of _season_, viz., the aptness of gout to recur in
spring and autumn, especially in its _early_ stages, is a very singular
feature.
The increased incidence at these particular periods of the year is, I
think, a striking proof of their deficiency in the defensive mechanisms
that enable normal persons to withstand with comparative impunity sudden
transitions from cold to heat, dryness to damp, and so forth. So it is
that rapid changes in the surrounding air, in its degree of warmth, or
its motion by wind are fertile of attacks. The east and north-easterly
winds of spring account for no few examples, as likewise inadequate
protection from cold or damp.
In short, a _variable_ climate is the most provocative of gout, that is,
most likely to elicit gouty manifestations in one predisposed thereto.
Conversely, stability in climate favours freedom from attacks. Thus some
obtain exemption from their gout by removing to a hot climate, others
when removed to one of cold, dry character. Doubtless these differences
in response hark back to _individual constitutional peculiarities_.
It is the vigorous plethoric persons, who eat too much, that do well in
dry, cold climates. The low temperature and dryness of the air stimulate
tissue changes, dispose them to active exercise with consequent increased
efficiency of digestion, assimilation, and excretion.
On the other hand, many victims of gout are spare feeders, with feeble
powers of digestion and metabolism, and for them a mild, moderately warm
and not too damp climate is the more suitable, involving, as it does,
less strain upon their capacities of adjustment.
If one may be permitted the generalisation, the ideal climatic
conditions for the gouty are low relative humidity, abundant sunshine,
and a low rainfall. But, alas! too often, permanent residence in such
desirable surroundings is unattainable, and the most that can be
compassed is a brief sojourn in some more congenial environment.
Still, some discrimination must be shown in the matter of choice, and the
physician, while mindful of the gout, must envisage the _individual_ as
a whole; for in advocating a change of climate his hope is that he may
remove or antagonise certain noxious influences and coincidently restore
the physiological machine as near as can be to a state of functional
efficiency.
The former purpose will often be fulfilled by mere withdrawal of the
subject for a time from his usual calling and environment. How frequently
will simple _rest_ and _recreation_ succeed when medicinal and other
forms of therapy have wholly failed! And how largely, may we remark, does
the Vis Medicatrix Naturæ work through the medium of things _psychic_,
not physical, to achieve its beneficent ends!
Still, not always is it _rest_ that is needed, and some regard must be
had to previous habits. Thus, for the _sedentary_, repair to a _bracing_
climate is indicated, some inland resort of moderate elevation, where
oxidation processes are quickened, and where if they eat more they take
more exercise, and so adequate elimination is assured.
On the other hand, for the elderly or old, or those enervated by
long-continued gout, a _sedative_ climate must be sought, one marked by
mildness, dryness, and equability. Bath, with its low diurnal range of
temperature, is eminently suitable for this class of gouty patient, who
often stand but ill the, for them, too stimulating qualities of more
bracing localities, such as Llandrindod, Harrogate, or Buxton, etc.
Frequently, however, our choice is dominated by some _associated morbid
affection_. Our patient may suffer from a so-called gouty _eczema_; if
so, he must avoid cold, damp places, or windy localities, and, for that
matter, sea air often, at first at least, aggravates the affection. Or
it may be that he suffers with “dyspepsia,” some catarrhal condition of
the alimentary canal, or a “sluggish liver.” For him, then, a dry inland
health resort of moderate or high altitude is preferable to one of sea
level, which will likely find him drowsy, indisposed to exercise, and a
prey to what he terms biliousness.
If _renal_ disease be a complication, he should seek a dry, warm climate,
and, if he can, winter abroad, say, in Upper Egypt or Algiers, which,
though it is warm and dry, is nevertheless somewhat marred by the wide
diurnal range of temperature and the not infrequent cold winds. If,
therefore, very sensitive to vicissitudes of temperature, the relatively
dry, warm marine health resorts of the Riviera are open to him.
If to go abroad is out of the question, one of the mild southwestern
seaside resorts at home is eligible, _i.e._, Bournemouth, Sidmouth, or
the more sheltered parts of Torquay, and Falmouth. Again, if he show
a tendency to _cardiac dilatation_, with or without valvular disease,
high altitudes will obviously be unsuitable, and dry, inland resorts of
moderate or low elevation should be given the preference.
Lastly, before despatching any gouty subject for a so-called change, it
is wise to elicit any personal _idiosyncrasies_ that he may be victimised
by. In other words, find out his most vulnerable points. Thus some gouty
persons are able to brave cold and damp with impunity, but pay dearly for
the slightest indiscretion in diet. They must therefore be warned that no
climatic change, however suitable, will absolve from the ill-effects of
improper or immoderate eating.
Others again—the majority—are extremely sensitive to atmospheric changes,
and such good as they might derive from a well-selected climate is
nullified through thoughtless omission of simple precautions against
“chills.” In short, the victims of gout can only ensure for themselves
the beneficial effects of _climatic therapy_ if, at the same time, they
vigilantly shield themselves from what experience has shown to be, in
their particular instance, the most fertile extrinsic or intrinsic source
of relapses or exacerbations of their disorder.
_Choice of Residence._—In these days it may savour of irony to talk of a
choice of residence where none is. Still, much of the benefit accruing
from a change of air will depend not only on the place resorted to, but
the situation of the dwelling or hotel, in which the subject takes up his
temporary abode. Thus in inland resorts some parts of the town may lie in
a hollow, others on adjoining slopes or plateaux at an altitude higher
by some hundreds of feet. Sites like the latter are obviously unsuitable
for the victims of cardiac dilatation, etc. Again, where the patient’s
condition is such that he must perforce spend a large portion of his time
indoors, it is a matter of some moment that the situation and aspect
of the building and, more pertinently, the subject’s suite or room be
ascertained before he takes up residence.
Apart from sanitary and hygienic considerations, the quality of the
cuisine, general comfort, class of society, have all to be thought of, if
the best results are to be obtained. They are not unimportant details.
How often is the benefit of a stay nullified by uncongenial surroundings,
by a gloomy outlook, the fret and jar of ill-assorted or discordant
elements, that forbid that cheerful intercourse that does much to restore
that sense of _bien-être_ so eagerly sought.
In short, attainment of the best results of climato-therapy can only
be achieved through the medium of a closer co-operation between those
who practise at health resorts or spas and the patient’s usual medical
attendant. But, meanwhile, for most of us, our dwelling place doth rest
upon our calling, and we may take this for our comfort that climatic
vicissitudes may be greatly mitigated by a _well-situated_ and _sanitary_
residence. I allude, of course, here to a _permanent_ abode, and the
gouty, if he enjoy any latitude, should live in a house built on a
_well-drained gravel soil on a slope, sheltered from the north and
north-east winds_.
Again, with the question of habitation is bound up the equally important
matter of _clothing_. By our forefathers _flannel_ underwear was deemed
the most eligible, despite its low or deficient power of absorption. But,
without discussing the various arguments adduced in favour of this or
that particular fabric, I would myself favour _silk_ as being, perhaps,
the ideal _underwear_; next to this a single woollen or woven linen
vesture, and it goes without saying that, prone to excessive sweating as
these gouty subjects are, frequent changes are essential. The feet of
the gouty are their weak spot, and, apart from the correction of _static
deformities_, flatfoot, etc., it is extremely desirable that they not
only be well shod, but be especially careful not to sit about in wet
boots or socks.
For the rest, their outer layers of clothing should be light, warm,
easy and not tight fitting. Extremely liable as they are to lumbago and
sciatica, they should be careful to enlist a thicker fabric than is usual
for the back of their waistcoats; while sufferers from sciatica may, with
advantage, insert a silk lining to the seat of their trousers.
Lastly, it is most important that the gouty, and of course all persons,
should dress according to the prevailing weather and not according to the
_time of year_. For them, more than any other class of person, to doff
summer and don winter clothing for no other reason than some arbitrary
date is fraught with mischances, freedom from which would be purchased by
a little commonsense.
EXERCISE
It has been wisely said that “those threatened with gout should imitate
as far as practicable and consistent with comfort the habits of
agricultural labourers,” for sedentary occupations and idle ways not
only favour the invasion of the disorder but hasten its recurrence.
How frequently, indeed, is it the direct outcome of an abrupt change in
habits—a hunting man, predisposed to gout, sustains an accident, can no
longer ride to hounds and takes to motoring. Unless he forthwith curb his
food intake, the disorder overtakes him. Sometimes misfortune proves a
blessing in disguise, as in the case related by Van Swieten of an opulent
and gouty old priest, who, captured by Barbary corsairs and forced to
work as a galley slave, soon lost his gout.
Again, it is notorious that in those in whom the brunt of the disorder
falls on the _lower_ limbs, the outlook is more sombre than in those more
severely crippled in the hands. In short, capacity for and willingness
to take adequate exercise is one of the most potent measures wherewith
to fend off the gout. The amount should be in proportion to the age,
strength, and previous habits. The exercise should be taken not after a
spasmodic but _systematic_ fashion. For erratic, like excessive, exertion
often converts the expected benefit into the exciting cause of an attack.
The aim should be not exhaustion but wholesome fatigue.
Young and fairly vigorous persons, if previously sedentary or indolent
in habit, should take regular exercise, gradually increased. In the
middle-aged, especially if obese, it should be graduated according to the
capacity of their circulatory organs, and more stress laid on respiratory
exercises and dietetic restrictions. For in their instance fatigue or
over-exertion is easily induced, often with grave consequences. Also, in
long-standing cases, neurasthenic from long-continued pain, it is well to
begin more or less tentatively, and in many cases to prescribe a course
of _massage_ before proceeding to active exercise. For not seldom such
subjects have but a small fund of nerve energy to draw upon.
In the gouty, even the malign influence of bad habits of living is
greatly mitigated by active exercise and labour. “The gout very rarely
visits the poor man’s cottage.” Nothing can so effectually counteract a
predisposition to the disorder, and what Sydenham thought of its value
we may guess from his trenchant remarks on horse exercise. “And, indeed,
I have often thought if a person was possessed of as effectual a remedy
as exercise is, in this and most _chronic_ diseases, and had the art
likewise of concealing it, he might easily raise a considerable fortune.”
In conclusion, if healthful exercise of the body is imperative for the
gouty, I need scarcely labour the desirability also of congenial and
adequate exercise of the mental faculties. Adequate, but not excessive,
lest, like Sydenham, it reacts in added sickness. Otherwise absorption
in some honourable pursuit will do much to dissipate that tendency to
introspection and depression so often born of the consciousness of an
ever-constant menace to long-continued health.
“Orandum est, ut sit mens sana in corpore sano.”
GENERAL MASSAGE
In judiciously prescribed and skilfully applied massage we have an
agent of pre-eminent value in the treatment of gout. Indeed, Sir
William Temple—a martyr to the disease—when speaking of the benefit
of “friction,” frankly stated that “No man need have the gout who can
keep a slave.” In this there is much truth, for the beneficial results
of massage are not confined merely to the affected joints or muscles,
but, as a result of the improved circulation, waste products are more
readily excreted, the nerve centres regain tone, and a general feeling of
_bien-être_ is promoted.
It cannot be doubted that general massage of the trunk and limbs
accelerates the elimination of the chemical outcasts of metabolism, and
simultaneously, by ensuring a more adequate supply of fresh blood to the
tissues, must result in an access of renewed vitality. Many, indeed, have
adduced experimental proof that such a quickening of the vital processes
does ensue after general massage. We should therefore, in elderly or
feeble subjects, or in those of sluggish habits, advocate from time to
time a course of general massage for its _prophylactic_ effects.
It is the more especially indicated in those gouty subjects prone to
attacks of _muscular fibrositis_—attacks of which are undoubtedly
favoured by the retention of the toxic and waste products of muscular
metabolism. Nothing, again, so facilitates the dissipation of exudates,
nodules, or thickenings in these structures, for the treatment and
prophylaxis of which massage is indispensable.
In enlisting the _prophylactic_ action of general massage, it is not
desirable that the _séance_ should exceed forty minutes, and it should in
all cases be followed by an hour’s rest; to practise it too soon after a
meal is inadvisable, and in those cases in which it favours the advent of
sleep it is best undertaken in the late evening.
In conclusion, I would urge the importance of more interest being taken
by the physician himself in the technique of massage, as I am assured
that, if rationally and perseveringly practised, it constitutes one of
the most valuable adjuncts in the prophylaxis of gout.
GENERAL HYDRO-THERAPY
That hydro-therapy constitutes one of the most effective, if not _the_
most effective, methods of treating gout, is almost a truism, if judged
by that most “acid test”—Experience. The particular applications we are
about to discuss entail _exposure of the whole body_. In other words,
those measures directed more especially to treatment of the _underlying
causal state_—the correction of that warp of metabolism or auto-toxic
state of which the arthritic, muscular, or other lesions are but local
manifestations.
It goes without saying that, with this for our objective, there is
much need for discrimination in the selection of measures suitable
for individual cases, and, naturally, the basis of such differential
treatment is _thorough physical examination_ prior to embarking on the
course. Yet how frequently on their own initiative do these subjects
enter lightly upon a series of baths, mingling stimulant and sedative
procedures in haphazard fashion, unwitting that hydriatric measures are
capable of infinite harm when misapplied.
For in hydro-therapy the personal equation is of prime importance,
varying with _individual reactive peculiarities_. In short, the character
of the response differs widely in different subjects, efficiency or not
of the nervous and circulatory functions being the chief controlling
factors. Hence accurate appraisement of the reactive powers of the
constitution to hot and cold applications is the basis of rational
hydro-therapy.
Thus _nervous irritability_ is _the_ outstanding characteristic of
some gouty constitutions. They are therefore intolerant of extremes of
temperature, and for them sedative or sub-thermal baths are the most
suitable.
Others suffer from _torpid circulation_ and _sluggish vascular response_,
and in their instance, stimulant measures, hot or cold, in sequence
or in alternation, are indicated. Again, some are _obese_, and others
_lean_, and while of the twain the former react more feebly, on the other
hand, they stand prolonged courses of hydro-therapy more satisfactorily.
In contrast, the thin, though they react well, are more readily
exhausted, and so apt to suffer from “secondary chill” or other untoward
consequences.
_Prophylactic Measures._—As we have noted, the “gouty,” more than others,
are intolerant of atmospheric vicissitudes. Accordingly, if we would
strengthen their defensive mechanisms in this respect, we must endeavour
to train them to react more adequately to _cold_ or _sub-thermal_
impressions.
Of the value of _thermal_ applications in chronic gout I am
convinced, but, on the other hand, we must not blind ourselves to the
value—_prophylactically_ speaking—of their judicious conjunction with
_sub-thermal_ or _cold_ procedures. For these latter stimulate oxidation
processes, and in chronic gout, according to many, there is deficient
oxidation of protein waste, while, apart from this, in the gouty obese
there is imperfect oxidation of adipose tissue.
Prophylactic measures to be of any real avail must be _continuous_,
and spas or hydropathic establishments should indeed be more alive to
their educational responsibilities in this matter, for the benefits
of hydro-therapy as regards prophylaxis are within the reach of all
possessed of the convenience of a modern bath-room.
They should be taught to inure themselves by taking daily a tepid bath
followed by a cold shower or rain spray. If this be too drastic, let
them, while standing in warm or tepid water, briskly rub the rest of
the body with a coarse towel wrung out of cold water, into which, if
liked, salt has been added to the point of saturation. In this way the
tonic effects upon the skin of hypo-thermal or cold applications may be
invoked, and thereby its undue sensitiveness is reduced and therewith the
liability to subsequent attacks.
It now devolves upon us to consider under what circumstances
hydro-therapy is inadvisable, and, incidentally, those ill-effects that
indicate its modification or abandonment.
_Contra-indications and Untoward Complications._—Authorities generally
seem unanimous on this point, viz., that the chief sphere of
hydro-therapy is in _chronic_ or subacute gout. On the other hand, they
are equally unanimous in proscribing its exhibition in _acute_ forms of
the malady. Speaking for myself of the Bath waters, I am quite convinced
that the distinguished physician, Caleb Hillier Parry’s pronouncement,
“that the Bath waters, in no form whatever, are beneficial during the
paroxysms of gout, or in any inflammatory disposition which may exist in
the interval,” is not only true but capable of extension to all forms of
hydro-therapy as applied at this stage of the disorder.
Nor do I think it advisable if _prodromal_ symptoms suggestive of the
imminence of an attack are present. It is too, I think, impolitic—after
the subsidence of a severe attack—to resort too quickly thereto, the
more especially if there is a disposition to what our forefathers termed
“flying gout.” In either event, an _acute outbreak_ is most likely to
ensue, and, though there is doubtless some truth in the old idea that a
gouty subject feels better after an attack, still it is not, I think, the
physician’s _rôle_ to evoke gout, but rather to prevent its explosion.
Occasionally mischances of this sort will happen, but only exceptionally,
if the foregoing safeguards be respected. Certainly if the patient seems
palpably on the verge of an attack it is but discreet to postpone baths
until the good effects of free purgation and strict dieting have been
derived.
Indeed, I would go further, in that I think that, under all
circumstances, a course of hydro-therapy should be preceded by _free
evacuation of the bowels_. We should then hear less of that disturbance
of the system known as “well-fever” or “poussée-thermale,” which, it
is not sufficiently recognised, may follow not only _internal_ but
_external_ use of mineral waters. I allude to _dyspepsia_, _lassitude_,
or _skin eruptions_, etc., symptoms which formerly were thought to be
of critical or beneficial nature, but which, I agree with Dresch, are
probably the result of an _auto-intoxication_, and, as he thinks, more
or less combined with an infection by the bacillus coli. Should such
symptoms supervene during a course, the baths had better be omitted
for two or three days _pending their disappearance_ under appropriate
measures.
In the same way, there are reservations regarding the suitability of
baths in _chronic_ gout. Thus, if complicated by advanced _cardiac_ or
_renal_ disease, hydro-therapy is often _contra-indicated_, and, in any
instance under such circumstances, has to be undertaken very cautiously.
On the other hand, it is wonderful how well many examples respond if
due discrimination be exercised. Especially suitable are those cases of
gout and _renal_ disease in which the _heart_ is hampered by increased
_peripheral_ resistance. Such cases under Aix massage, frequently, as
Bain and Edgecombe pointed out, improve strikingly through the consequent
reduction of arterial pressure.
Turning now to the _untoward results_ or _complications of
hydro-therapy_, hot baths, if of too high a temperature or too
prolonged, may cause _vertigo_, _fainting_, or _palpitation_—an
indication for reduction in temperature and duration. Or, if douches
are used, the pressure may be excessive. _Insomnia_, again, may follow
over-stimulation, and our measures must be altered accordingly. Loss of
appetite and strength, too, may be the outcome of too drastic treatment
and excessive reaction.
It is well, also, that during a course of hydro-therapy the patient’s
body weight be taken from time to time, and note made whether he is
gaining or losing in muscular strength. If weight sink and, coincidently,
strength increase, all is well with the gouty obese; but if muscular
capacity be waning, excessive demands are being made on the subject’s
oxidising and eliminative processes.
Examination of the _urine_, too, may yield indications of value. A
notable increase in the output of _chlorides_ suggests excessive tissue
waste, and of _phosphates_ too marked excitation of the nerve centres,
and the appearance of albumen or sugar, if previously absent, will
indicate reduction in intensity of the hydriatric procedures. In short,
we should be alive to the profound influence of hydro-therapy on general
metabolism and the consequent necessity of medical supervision throughout
the course.
METHODS OF APPLICATION OF GENERAL HYDRO-THERAPY
Subject to reservations, stimulant hydro-therapeutic procedures are in
_chronic_ gout _the_ special indication. Thermal waters, therefore, are,
generally speaking, the most suitable, and _cæteris paribus_, the higher
the temperature the greater the excitant action. Of natural thermal
baths, those of Bath, Aix-les-Bains, Gastein, Wiesbaden, etc., enjoy
great repute, and, judging from personal experience of the first-named
spa, I doubt not that—given due discrimination—all waters of this group
are unquestionably beneficial.
Having regard to their _radio-active_ properties, the best results are
undoubtedly to be obtained by a combined bath, drink, and inhalation
cure. Simple immersion baths, deep or reclining, with or without massive
under-current douches, enjoy well-deserved vogue for their general and
local effects.
Moreover, as the local douching exerts a sedative as well as a resolvent
effect, they prove most useful not only in articular gout, but in the
treatment of those frequent concomitants, _lumbago_ and _sciatica_. Their
efficacy is much enhanced by coincident or subsequent massage, and to
increase the powers of resistance, such hot baths should be followed by
graduated sub-thermal or cold applications.
Sool-Bader, or natural thermal brine waters, exert a similar effect,
but such are not available in this country. But cold brine baths—given
at temperatures of 98° F. and upwards—are obtainable at Droitwich,
Harrogate, and Builth, and are invoked more particularly in long-standing
cases with great thickening of the arthritic or related muscular
structures.
Again, gouty subjects not seldom suffer with _high blood pressure_,
and our treatment must be modified accordingly. Here we may enlist
what are known as _Aix massage_ baths, which tend to _lower_ arterial
pressure through the profound influence they exert on metabolism, and
the elimination of toxic and waste products. As in warm immersion baths
enervating after-effects are apt to ensue unless the tonic-bracing action
of a _terminal cold application_ be invoked. On the other hand, in some
cases of chronic gout the abdominal musculature is very flabby, with a
tendency to _visceroptosis_ and _low blood pressure_. In their instance,
a _Vichy bath_, inasmuch as it tends to _raise_ the blood pressure, is
preferable to Aix massage.
Another powerful method at our disposal for the elimination of waste
products is the _vapour_ bath. It is not suitable for the old and feeble,
or those with advanced _cardiac_ or _renal_ disease, but it is especially
adapted to gouty subjects with _harsh_, _thickened_ or _irritable_ skin,
and those of _obese_ habit.
While the foregoing procedures, generally speaking, are eligible for the
more robust type of individual, we must have regard also to those of
delicate constitution, whose strength is sapped by long-continued gout,
or who show signs of pre-senilism. In such instances, _sub-thermal_ baths
(82° to 97° F.) have a great sphere of usefulness. Thus in the presence
of _high arterial pressure_, a course of immersion baths, say, at 93° F.,
combined with fan douches, and applied according to the Bourbon-Lancy
method, are very effectual in reducing arterial tension. Of marked
_sedative_ action, such neutral baths are peculiarly eligible also for
all types of gout associated with _insomnia_, irritable skin affections,
or showing signs of vasomotor instability.
Moreover, these sub-thermal baths are valuable in articular gout of
subacute or lingering character if the douches used are of low pressure,
which latter is essential if the joints are sensitive. Their therapeutic
action is of course more pronounced in those _natural mineral waters_
which more nearly fulfil the requirements of a neutral bath. Such
are possessed in high degree by the waters of Buxton, Ragatz, and
Baden-Weiler, the average temperature of which approximates to the point
of thermal indifference.
METHODS OF LOCAL HYDRO-THERAPY
In one form or another, _douches_ have for centuries been used for
chronic joint affections. Three factors have to be considered—the volume,
pressure, and temperature of the impinging water. The size and form of
the stream determine its thermic and mechanical effect, and _cæteris
paribus_, the more massive the volume, the more marked the results
produced.
The pressure, again, is a most important factor, as the influence on
the circulatory and lymph flow in deep-seated tissues is directly
proportional to the force of delivery.
We see, therefore, that in douches we have a weapon of great power for
good or ill, and the results achieved will be exactly proportional to the
judgment displayed in meeting individual requirements in the matter of
their temperature, duration, and pressure.
The space at our disposal forbids entering into great detail, and a few
general principles are all that can be enunciated. Thus, while extreme
pressures are permissible in selected cases, they are contra-indicated
when dealing with regions the seat of pain. In such instances we should
always begin with mild measures, viz., a tepid fan or spray douche (80°
to 92° F.) of low (4 to 8 pounds) pressure. These later may be replaced
by a hot (104° to 110° F.) broken jet, or rain douche, of 10 to 15 pounds
pressure, and by such graduated procedures pain will often be relieved.
For the relief of _stiffness_ and _swelling_ alternating jets or sprays
are most suitable, the hot and cold douches being each of fifteen to
thirty seconds duration. The more remote the extremes of temperature, and
the more abrupt the transition from hot to cold, the greater the excitant
effect.
Simultaneous massage greatly reinforces the stimulating and absorbing
action of douches, which latter also may in various ways be
advantageously combined with other local procedures, viz., local vapour,
hot air, and electric light baths.
TREATMENT BY HYPERÆMIA
Enhanced oxidation and destruction of nitrogen-containing waste and
toxins being one of the primary indications in the treatment of all
so-called auto-toxic states, it is not surprising that hot air baths—both
_luminous_ and _non-luminous_ types—are so extensively employed in gout,
either for their curative or prophylactic action.
For the practical details of their administration I must refer the reader
to special works on the subject, contenting myself with a brief reference
to their therapeutic indications. While all gouty subjects at some period
of their life-history may be eligible for hot air baths, their use is
contra-indicated in _pyrexia_. Nor are they appropriate if the case is
complicated by any irritable _skin condition_, or in the graver forms of
_glycosuria_. They are unsuitable, too, if there are any evidences of
_hyper-thyroidism_, from which the gouty, no more than others, are immune.
Again, in _cardiac dilatation_ they must be exhibited with great caution,
and where extreme, are of course impermissible, as also in the later
stages of _chronic nephritis_. On the other hand, they are eminently
suitable for the treatment of _fibrositis_ in gouty persons, especially
of obese type, nor does the presence of _glycosuria_ in such association
constitute a bar to their use.
Moreover, as a _prophylactic_ measure, they are extremely well adapted to
those victims of gout who lead sedentary lives, as to a limited extent
they counteract the evil effects of muscular inactivity. Here also, by
the judicious use of graduated after-applications of cold or hypothermal
grade, the undue sensitiveness of the skin in these subjects is reduced,
and their liability to so-called “liver chills” diminished.
In conclusion, it is the proper blending of their eliminative and
prophylactic qualities, according to individual needs, that constitutes
the key to rational treatment by hyperæmia. These same postulates are
applicable also to the various peat, mud, and fango baths, whose action
in essence depends on the varying degree of hyperæmia they produce, and
to which, in all probability, their well-established efficacy in gouty
affections is attributable. That there are other valuable accessory
methods of treatment—electrical, hydro-electric, etc.—in vogue at spas,
I am perfectly aware, but the number of special works available for
reference on this point relieves me of the necessity of alluding to them
in detail.