CHAPTER XXXII

MINERAL SPRINGS AND CHOICE OF SPA

MINERAL SPRINGS

Though many have tried, no one has yet been able to define exactly what

does and what does not constitute a “mineral water.” Criterion after

criterion has been suggested—chemical, therapeutic, thermic, cryoscopic,

ionic, etc.—but to all there seem objections, and doubtless will be,

pending the advent of more exact knowledge regarding these—the most

complex pharmacological compounds in our Materia Medica.

Naturally, “mineral waters” being so refractory of _definition_, it

follows that all suggested _classifications_ are equally perplexing. In

fact, all attempts to reduce them to order according to their generic and

specific differences are, it must be admitted, unsatisfactory. Perhaps

the most serviceable differentiation at our disposal at present is one

based on their _chemical_ composition. As Sir Hermann Weber says, “a

statement of the salts contained in a mineral water often tells the

ordinary medical man something of the nature and probable effects of the

water in question, whilst the results of an analysis expressed in ‘ions’

would simply bewilder him.”

“Probable effects,” says Weber, and, I think, advisedly; for in

estimating the effects of spa treatment how difficult to discriminate

between what is due to “mineral waters” and what is due to change of air,

diet, mode of life, and mental occupation. Yet, again, how bewildering

the fact that “waters” of the most varying chemical content prove to be

equally beneficial in gout. Small wonder, then, that physicians sought to

refer their therapeutic efficacy not to their mineral constituents, but

to the vehicle common to all of them, viz., to the diluent and solvent

action of the _water_ itself, its flushing effects in washing out urates

and other toxic substances.

From this it was but a short step to the further assumption that, other

things being equal, the drinking of water at home would do just as well

as resorting to a mineral spring. But, as has been shrewdly said, the

“other things” never are “equal.” What of the daily worries left behind,

the change of air and scene, the modifications of diet, the leisure for

outdoor exercise, not to mention hydro-therapy and other integral or

collateral factors of spa treatment?

But, even frankly admitting our ignorance, the lessons of experience,

nevertheless, can neither be flouted nor ignored, least of all in the

treatment of gout. “Mineral waters” are but used _empirically_, says

the critic, forgetful that the use of _colchicum_ lies open to the same

aspersion. Especially valid the imputation, as he thought, in regard to

the so-called “simple” or “indifferent” thermal waters. These—despite the

testimony of centuries to their worth—must be discarded in favour of some

pseudo-rational method, and this, forsooth, because their mode of action

seems inexplicable! Yet, by the irony of Fate, within a brief span these

“indifferent” waters were found to contain a substance—“radium”—whose

powers few, at present, pretend to gauge or limit. There seems, in truth,

a peculiar fitness in the coincidence that it should be in this very

group that experimental investigations have proved so fruitful.

Is it not, moreover, a striking fact that the waters of nearly all the

natural springs which for centuries have been used in the treatment

of gout are thus dowered, and those which are most lowly mineralised

seem to possess the greatest degree of radio-activity?[63] It was to

their possession in varying measure of this common property that the

therapeutic efficacy of waters so widely different in their chemical

content was presumably in large part attributable, viz., to their

_radio-activity_.

For alike in simple thermal, sulphurous, alkaline, sulphated alkaline,

or muriated waters, the presence of radio-activity has been established.

But if, _e.g._, in the _simple thermal_, their therapeutic potency is

referable to their higher degree of radio-activity and not to their

mineral content, in others their relative deficiency in radio-activity

is compensated for by their _mineral_ constituents—these present in

sufficient quantity to exert a _specific_ action, alterative, aperient,

tonic, etc.

In this matter of _mineral_ content we are reminded of the grievous

controversy that has long obtained with regard to the use of natural

waters, the chief constituents of which are _sodium_ salts. Sir William

Roberts, as we know, from his experiments, ascertained that sodium

salts promoted the conversion of the quadriate into the biurate, thus

augmenting the precipitation of the latter.

This behaviour on the part of the carbonates, bicarbonates, and

phosphates of sodium led him to the sweeping generalisation that all

sodium salts, including the chloride, were, as far as practicable, to be

avoided by _gouty_ subjects. Naturally, in conformity with this view,

such patients were warned to flee those spas whose waters contained these

peccant salts.

Carried to its logical end, this dictum would have cut the gouty off

from, _e.g._, the carbonate of soda waters of Vichy, the chloride of

sodium springs of Homburg, the sulphate of soda waters of Karlsbad, not

to mention the muriated (sodium chloride-containing) sulphur waters of

Harrogate, Llandrindod, etc., despite the overwhelming clinical evidence

as to their efficacy in certain cases of gout.

Fortunately, as Burney Yeo observed, “in spite of all the theoretical

denunciations of the use of sodium salts in gout, the gouty, from all

quarters of the globe, have resorted, and continue to resort, in steadily

increasing numbers, to those Continental springs in which the salts of

sodium are overwhelmingly predominant.”

In short, Sir William Roberts’s experiments, while they dissipated the

fallacious view of the action of alkalies as solvents in the blood of

sodium biurate, have not for one moment imperilled the clinical and

practical estimate, deep-rooted in experience, of their general utility

in gout.

For myself, I incline to the view of the French authors, who would refer

the value of alkalies and alkaline mineral waters in gout rather to

their general influence on metabolism than to the now no longer tenable

conception of their solvent action on _uric acid_.

Reflecting on the varied constituents of mineral springs and the claim

that each and all of them are of value in gout, one naturally looks for

certain conditions common to them all. These are, as Burney Yeo rightly

says,—

(1) The quantity of water, more or less pure, taken into the

body under regulated conditions daily.

(2) The altered mode of life, the regular exercise in the

open air, the modified diet, the early hours, the absence of

business cares.

(3) In many foreign spas there is the drier and hotter

Continental climate.

(4) The stimulating effect to excretion and “tissue change”

which the baths, douches, frictions, and manipulations applied

at most of them induce.

Now, admitting, as one freely does, the important influence exerted by

these factors on what may be termed the pathological groundwork of gout,

still it is equally certain that some cases of gout do better than others

at certain spas.

This leads me on to the further reflection that the favourable or

unfavourable reaction in different cases depends on the varying nature of

what I may term the “excitants” of gout. For the deviations from health

that evoke the disorder are manifold and diverse, each carrying with it

its own therapeutic indications. Something more is needed than what may

be termed a blind or unintelligent “washing out” process. In every gouty

patient there is some functional flaw or defect, and _cæteris paribus_,

that natural spring will suit him best whose mineral or other content is

best calculated to correct or minimise his particular deficiency.

In short, we must get rid of our too common habit of asserting that this

or that particular water is “indicated in all cases of gout,” and its use

“attended with the most remarkable results.” The question that we should

be more anxious to decide is, whether of _all natural springs_ this or

that particular mineral water is _par excellence_ the one that will most

surely and most swiftly correct or minimise that particular functional

derangement which in the subject under review experience has shown to be

the most fertile source of gouty outbreaks. But to this we shall refer

later when dealing with the _individual peculiarities_ upon which our

_selection of a spa_ will depend.

To sum up, in consonance with these views, the general principles of spa

treatment, as I take it, are:—

(1) To correct or relieve those functional derangements,

gastro-intestinal or other, that appear to be the determining

causes or excitants of outbreaks of regular gout.

(2) To reduce the toxicity of the blood plasma and tissues by

promoting the elimination of uric acid and toxins through all

avenues of excretion.

(3) To restore the organism as far as possible to a state

of health or functional efficiency, and therewith to adopt

such prophylactic measures as shall diminish the liability to

recurrence of the disorder.

To discuss the application of these principles to all types of mineral

waters is beyond the compass of this work, and I shall perforce have

to confine myself very largely to discussion of the salient properties

of _radio-active_ waters, with subsequently such brief allusions to

the salient therapeutic indications of other varieties as may be

indispensable to intelligent selection of a spa in any individual case.

RADIO-ACTIVE WATERS

As to the physical properties of _radium_, it is, according to the

theory of transformation, a “changing element,” emitting alpha, beta,

and gamma rays, and in addition a radio-active emanation. This latter

product exists in a gaseous form, and is the outcome of the ceaseless

metamorphosis taking place in radium itself, each atom of which

continuously ejects at high velocity an atom of helium.

This expulsion of helium having ensued, the parent atom no longer exists

as radium, but as _radium emanation_, or _niton_, as it has more recently

been designated. Now, from a therapeutic point of view, the salient fact

is that elicited by Lowenthal, viz., that the active agent is not, as

was previously thought, radium itself, but the _emanation_ derived from

it.[64]

Now, as a reference to our footnote shows, the Bath waters are

radio-active to a remarkable degree, and as Maché, Curie, and Laborde

hold that “the higher the emanation from a given spring, the more

striking are the physiological results,” a brief reference thereto seems

called for.

_Physiological Action of Radium Emanation._—When inhaled, radium

emanation swiftly passes from the alveolar spaces of the lungs into the

blood, and thence to the tissue cells, which, according to their specific

solubility, absorb the same. Eventually, if the inhalation is prolonged

sufficiently, saturation of the blood therewith ensues, to be followed by

its escape _viâ_ the lungs, intestines, kidneys, and skin.

Taken orally, radium emanation, according to Lazarus, in large amount,

passes into the arterial blood, an observation confirmed by other

investigators experimenting on animals. Its absorption into the blood

takes place slowly from the intestines, and its exit thence out of the

system is, in like fashion, only slowly effected, taking _hours_ for

complete excretion. On the other hand, when _inhaled_ the emanation is

quickly absorbed and as swiftly excreted, _i.e._, within a few _seconds_.

As to its power of penetrating the _skin_ most authorities are sceptical,

but Engelmann stoutly contends that he has proved that in immersion baths

the emanation does actually pass through the skin; but pending further

researches this question of cutaneous absorption must remain _sub judice_.

Again, radium emanation appears to be endowed with the power of

energising or activating the body ferments or enzymes, in other words,

can stimulate to greater efficiency the _proteolytic_, _glycolytic_,

and _diastatic ferments_ that set in motion that long chain of

cleavage processes in the various foodstuffs, the necessary prelude to

their absorption, assimilation, and ultimate transmutation into live

protoplasm. Nay more, for the same mysterious agent, it is claimed, can

activate those oxidising enzymes which initiate the equally intricate

disruptive processes that mark the disintegration of living protoplasm.

Thus Neuberg, Lowenthal, Edelstein, and others contend that they

have demonstrated such an increase of efficiency on the part of the

autolytic enzymes responsible for cleavage of the protein molecule into

nitrogenous bases and amido-bodies. That radium emanation should exert

such a profound effect on organic metabolism, both in its anabolic and

katabolic phases, would, if established, go far to dissipate the dark

shadow of empiricism that has for so long clouded the practice of mineral

water drinking and bathing. For it is precisely in those conditions

collectively termed “disorders of nutrition” that radio-active waters

have found their traditional _rôle_.

INFLUENCE ON URIC ACID METABOLISM

In 1909 Gudzent, working in His’s clinic at Berlin, affirmed that in

gouty subjects uric acid vanishes from the blood in the presence of

radium emanation; moreover, that under the same conditions tophi had been

observed to melt away. The explanation proffered by Gudzent was, that the

emanation inhibited the transmutation of the unstable and more soluble

_lactam_ into relatively insoluble and stable _lactim_ urate, this latter

being the salt found in the blood of the gouty.

W. His also claims that the gouty individual benefits by this method of

treatment, which, he maintains, not only reduces the uric acid content of

the blood, but dissipates uratic deposits in the tissues. On the other

hand, at the last Congress of Internists at Wiesbaden (1912) Gudzent

and His’s views, though stoutly supported by some, were unacceptable to

others, who, although they admitted the favourable influence of radium

emanation upon the symptoms of gout, yet contended that its effects could

with difficulty be interpreted either in the sense of increasing the

solubility of the monourate of sodium or its decomposition into CO₂ and

ammonia.

Thus E. V. Knaffl-Lenz and Wiechowski, working in the Vienna

Pharmacological Institute, were unable to confirm Gudzent and His’s claim

that treatment by radium emanations resulted in destruction or increase

in solubility of the mono-sodium urate. On the other hand, in view of

the admittedly favourable effect of the emanation on gout, they suggest

that it might be due to what they term activation of an uric acid oxidase

existing in the human tissues. Yet another view is that in some obscure

way radium emanation facilitates the elimination of uric acid through the

kidneys.

In regard to the claim that radium emanation has the power of keeping

uric acid compounds in their more easily soluble forms, it is interesting

to recall the conclusion arrived at by the _Lancet’s_ special commission

for investigation of the Bath waters: “The thermal waters of Bath exert a

distinct solvent action on uric acid; in our experiments, _e.g._, it was

shown that Bath waters dissolved over five times the amount of uric acid

that distilled water would similarly take up at blood heat—_i.e._, just

under 100° F. Since the waters are drunk hot and used hot for bathing

purposes, this fact may have an important relation to the therapeutics of

Bath waters in the treatment of chronic gouty affections and rheumatism.”

_Increased Excretion of Uric Acid._—Delayed excretion of exogenous

purin is held to be one of the most characteristic signs of gout. Now,

following emanation treatment, Lowenthal and others have noted that this

disability on the part of the gouty was apparently removed. For when, at

the close of the course, the capacity for dealing with exogenous purins

was tested by the intake of large amounts of purin bodies, excretion of

the same ensued after a normal fashion. It would seem then that there is

not only increased uric acid excretion actually during the progress of a

_séance_ of emanation, but also that this enhanced power of coping with

purins is maintained subsequently.

_Subjective Phenomena of Gout in Relation to Blood Content and Excretion

of Uric Acid._—Now, as we have seen, it is claimed that uric acid

disappears from the blood in the presence of emanation. But, while in the

majority of instances amelioration of symptoms follows reduction of the

uric acid blood content, in others improvement ensues even though the

amount of uric acid in the blood remains unaltered.

Thus in one of His’s patients under radium emanation striking amendment

followed notwithstanding that the blood contained uric acid. In another,

the subject of multiple tophi, no uric acid was found in the blood

throughout the treatment, and yet the victim had repeated attacks of gout

during this period.

Turning to the _excretion of uric acid in the urine_, similar

discrepancies emerge. Thus Mandel out of seven gouty patients under

treatment by radium emanation found that an increased uric acid excretion

ensued in two subjects. Of the remainder, in two no alteration in average

excretion took place, in two a slight diminution, and in one a marked

increase, to the extent of 50 per cent.

Now in four of the seven cases an undoubted clinical and subjective

improvement was observed, although the uric acid curve showed diminution

rather than increase. It seems, therefore, clear that the _beneficial

effect of radio-active waters in gout_ involves something more than

the _dissipation of the uric acid in the blood_ and _its increased

elimination in the urine_.

THERAPEUTIC ACTION AND APPLICATION

We have in previous sections emphasised the importance of treating _local

foci of infection_, in view of their possible causal relationship to

gout. For, uncertain as we are of the etiology of the disorder, we cannot

afford to neglect treatment of any possible source of toxic absorption.

Now a significant number of independent workers contend that in the

presence of radium emanation the growth of organisms is retarded, if not

actually inhibited. The same bactericidal power has been claimed for

radio-active waters even of low grade. Should recent contentions as to

the efficacy of the same in states of _oral sepsis_ be confirmed, it will

constitute an important weapon wherewith to combat not only the local,

but the remote malign, effects of sepsis in the mouth or its accessory

cavities.

Again, it is recognised that _pharyngeal_ and _nasal_ affections when

present derive benefit from the _inhalation_ of _radio-active waters_

atomised by steam or air. In this connection it may be noted that, by

an ingenious apparatus installed at Bath, the natural “niton” gas is now

extensively used for inhalation or douching of the mouth and neighbouring

cavities.

_Alimentary Disorders._—Accepting the fact that _gastro-intestinal

derangements_ are the most common _excitants_ of gouty outbreaks, it

seems to me highly probable that the good effects of radio-active waters

are partly attributable to their mysterious power of _activating the

body ferments_. Thus, through their stimulating action on the digestive

enzymes, they may inhibit the formation of abnormal substances, or,

through their quickening of the autolytic ferments, may hasten the

disruption and excretion of such when formed.

How frequently in these cases do we find that some functional hepatic or

gastro-intestinal derangement is the prelude to a gouty outbreak. Again,

as pointed out, how often do these subjects suffer with fermentative

dyspepsia and “organic acidity,” with associated lowered tolerance

for carbohydrates. In such cases, if given in copious quantity and

frequently, the radio-active waters prove most beneficial. This is in

part attributable to the mechanical flushing of the alimentary canal

and tissues, and in part perhaps to their activating influence on the

digestive enzymes.

In contrast to the foregoing, such abundant ingestion of the waters

is inadvisable in atonic types of dyspepsia marked by dilatation and

diminished secretion. But here again, if given in small amounts,

radio-active waters undoubtedly exercise a beneficial effect. Also in

those gouty subjects who suffer from neurasthenia and nervous dyspepsia a

similar favourable reaction is frequently observed. This I apprehend to

be due to the fact that radium emanation exerts a _sedative_ effect on

the nervous system. Thus it has been noted that guinea-pigs when exposed

to radium emanation drop into a state of somnolence and torpor. May not

this account for the undoubted fact that highly strung individuals when

subjected to a combined bath, drinking, and inhalation cure become less

irritable and lose their distressing tendency to insomnia?

Again, _intestinal irrigation_ with these radio-active waters after

the Plombières technique is justly esteemed in those cases of gout

attributable to intestinal catarrhs and mucous colitis. The constipation

these subjects so frequently suffer from is counteracted, and the regular

removal of waste and toxic material achieved.

As to the morbid affections associated with gout, notably fibrositis, it

is well recognised that muscular and nerve types of this disorder prove

very amenable to a course of these waters. Here I would lay stress, too,

on the swiftness with which the _glycosuria_ of gouty subjects vanishes

under the same conditions. The pruriginous and eczematous eruptions met

with are also favourably influenced by a combination of internal and

external treatment. I may note, too, that this mode of therapy is not

contra-indicated in _increased arterial blood pressure_. For it has been

shown by Deutelmoser, Saubermann, and others that under the influence of

radium emanations the blood pressure is reduced.

As regards the administration of radio-active waters, it cannot be

doubted that the combined bath, drinking, and inhalation cure is the most

advantageous. The subcutaneous injection of radio-active waters does not

seem to possess any outstanding advantages, while the danger of sepsis

has always to be considered.

As to the relative merits of artificial as opposed to natural

radio-active waters, it does not appear to me that the therapeutic

action of the former is swifter or more infallible than the products

that issue from nature’s laboratory. The limitations and capacities of

the latter have been fixed by centuries of experience, and, as far as

present researches go, the newly born commercial imitation, at any rate

as regards the treatment of gout, has yet to prove itself endowed with a

greater range of therapeutic efficacy.

CHOICE OF SPA

While naturally my attention has been largely centred upon the mineral

waters of Bath, I would by no means convey the impression that a _thermal

radio-active_ spring is the only one that I think beneficial in the

treatment of gout. Far from it, for if, from my description, I appear to

have claimed such to be universally applicable to all gouty subjects, the

explanation really resides in the fact that the resources of most spas

can be readily adapted so as to suit different kinds of cases.

Nevertheless, as I have said, I favour the tendency towards

_specialisation of spas_, as bit by bit the indications for their

differential application become more and more sharply defined. In view,

then, of this trend, it is manifestly only fair to our patients that we

endeavour to select that particular spa that seems most eligible in their

particular instance.

Let us assume, then, that the subject is in such circumstances that a

certain latitude of choice is permissible. This being so, the physician’s

selection will be the more satisfactory if regard is had not only to the

gout, but to the _individual_ himself, and not the least important of

the considerations involved have been already embodied in my remarks on

_climato-therapy_. For the ideal sought, if I may again say so, is not

only _physical_, but _psycho-physical_; and the physician who leaves out

the mental element will scarcely choose wisely.

Narrowing our field to consideration of the _physical_ requirements of

the subject under review, what manner of man is he, _metabolically_

speaking? Is he of _spare_ habit, one in whom katabolic changes hold sway

and “the vital fires blaze more fiercely,” or is he _obese_, one in whom

anabolic processes are dominant, with hoarding up of substance?

Now, I have taken these two types, the _spare_ and the _obese_, as in

gout we are dealing primarily with a “disorder of nutrition.” _Cæteris

paribus_, we wish to correct the morbid metabolic trend, in other words

provide differential treatment. Obviously the salient indication in the

_lean_ individual is that he shall drink of a spring which will tend to

enhance digestive capacity and facilitate assimilation of foodstuffs,

with as its outcome increase of general nutrition.

To compass such effects, _muriated_ chloride or common salt waters are,

other things being equal, most desirable; that is to say, unless they

are taken in such quantities as to produce catarrh of the stomach and

intestines, they _do not cause emaciation_. On the contrary, I have,

for example at Llandrindod, seen an increase of weight in these persons

ensue during, and, moreover, continue after, a suitably arranged course

of these waters. Among other muriated waters in this country may be

mentioned Llangammarch Wells, which, as Sir Hermann Weber suggested, is

suitable in cases of chronic gout, “especially where any emaciation is to

be avoided,” and Woodhall Spa also deserves mention in this connection,

or, reverting to the Continent, the waters of Homburg, Kissingen,

Wiesbaden, Baden-Baden, etc., may be selected.

The _muriated_ (chloride-containing) _alkaline_ waters are also eligible

in cases where loss of flesh is to be avoided, such as Ems, Royat,

Chatel Guyon, or La Bourboule. They should, for this reason, be given

the preference over the _simple alkaline_ waters, such as Vichy, Vals,

Neuenahr.

Reverting now to the _obese_, plethoric type of man, a heavy eater and

often of sedentary habit, what is the end to be achieved? Here loss

of flesh is to be courted, and a spa sought whose mineral waters will

by their action supplement the all-important dietetic and regimenal

treatment of the subject.

The class of waters pre-eminently suitable will be those known as

the _sulphated_ and the _sulphated alkaline_ varieties, which, taken

internally, will through their purgative and diuretic effects assist our

purpose. The stronger varieties of the _sulphated_ waters are chiefly

used as occasional aperients at home, as, generally speaking, at the site

of the spring there is no proper spa accommodation. We allude to Franz

Joseph, Hunyadi Janos, Rubinat, and Condal waters, etc.

In England several _sulphated_ springs exist, but, as far as their use

is concerned, may be regarded as obsolete. Perhaps the best known is the

original spring, no longer used, at Epsom, whence the English term for

magnesium sulphate, “Epsom salts.” According to Weber, in Charles II.’s

reign these native laxative saline waters were taken at the wells early

in the morning, and Pepys in his diary tells how on August 11th, 1667, at

seven o’clock on a very cold morning, he found many people drinking the

waters at Barnet Wells.

It is, however, the _sulphated-alkaline_ springs that have achieved

the greatest reputation in this sphere, notably Karlsbad, Marienbad,

Franzensbad, Tarasp Schuls, etc., and perhaps of these Marienbad is the

most frequented. But in any case, in exercising a choice, we should take

into consideration not only the temperature and mineralisation of the

waters and their balneo-therapeutic resources, but also the climate and

the time of year. Thus, for example, the climate at Tarasp is alpine,

and the altitude of Marienbad is over 2,000 feet, while that of Karlsbad

is but 1,200. Another point to consider is whether the obesity of the

subject is attended with _anæmia_. If so we may with advantage choose

Tarasp, which, in addition to sulphated alkaline, has _chalybeate_

waters, and the same dual advantages are to be found at Marienbad.

For those unable to go abroad the _muriated sulphated_ waters of

Leamington or Cheltenham in this country are available. The flat

contour of these spas is very suitable for those cases in which obesity

is complicated by cardiac debility. I may note, too, that Bain and

Edgecombe, discussing the treatment of obesity at Harrogate, speak well

of the strong _muriated sulphur water_, substituted in anæmic cases by a

chalybeate water in conjunction with an aperient.

So much for the broader indications, _metabolically_ speaking, that

should guide us in our choice of a spa. And now to consider other special

conditions which in the gouty call for consideration, notably digestive

disorders.

_Dyspepsia and Chronic Gastro-intestinal Disorders._—In these conditions

it is especially imperative that we take a broad view, particularly

in respect of climate and altitude. Inland spas at moderate or high

altitudes are generally preferable. Doubtless the beneficial result

is in part due to the influence that change to a mountainous region,

with abundant open-air exercise, exerts on the nervous system. But the

same has its drawbacks in the “gouty dyspeptics,” for often, as I have

observed, they tend at first to overeat. As Weber rightly says: “The

feelings of ‘sinking’ and ‘lowness’ in the gouty and dyspeptic are

frequently mistaken by the patients themselves as indications for taking

food, stimulants, or tonic medicine.” In short, we must in their instance

institute immediately at the commencement of their course the requisite

dietetic innovations. Again, being in these more bracing localities

more disposed to take exercise, the adverse effect on digestion of

_over-fatigue_ must be guarded against.

Indeed, in the more aggravated types of so-called gouty dyspepsia there

is little doubt that sojourn in a _sanatorium_ may at first be advisable,

so that the patient’s digestive disabilities may be thoroughly studied by

the help of test meals, while dietetic treatment can be more readily and

surely supervised.

Passing to the question of _mineral waters_, there is no doubt that a

previous investigation of the _secretory_ and _motor_ functions of the

stomach would supply valuable indications as to the type of “waters” most

suitable. Incidentally, too, researches in this line might tend to clear

up the obscurity that enshrouds the mode of action of mineral waters in

cases of gouty and other forms of dyspepsia. For experimental findings

and clinical observations are here somewhat conflicting.

Thus it has generally been supposed that _simple alkaline_ mineral waters

promote the secretion of acid gastric juice. But Pawlow, experimenting on

dogs, found that alkaline sodium salts tended rather to _inhibit_ than

to stimulate gastric and pancreatic secretions. In order, therefore, to

reconcile his findings with the well-ascertained benefit that follows

their exhibition in gastric disorders, he suggests that they prevent the

too prolonged or excessive secretion that is so often a concomitant of

catarrhal conditions.

Adolf Bickel, again, has confirmed Pawlow’s conclusion that the simple

alkaline group of mineral waters depress rather than stimulate the

secretory activities of the gastric mucous membrane[65]; but Sir Hermann

Weber, discussing Bickel and Pawlow’s deductions, puts forward, as I

think, a more reasonable hypothesis than that advanced by the latter

authority.

Thus he suggests that “a possible explanation of the beneficial

effects of alkaline salts in many digestive disorders (gouty dyspepsia,

irritable hyperacidity, etc.), in tendency to ‘biliousness,’ and in

various so-called ‘gouty manifestations’ is that these salts when

taken up into the circulation exercise a favourable influence on the

metabolic processes generally, thereby improving the general health and

thus indirectly, apart from any special local action, helping to remove

conditions of dyspepsia, gouty bronchitis, etc.”

From his experiments Bickel came to the conclusion that in conditions of

_subacidity_ supervening on chronic gastric catarrh the most suitable are

_muriated_ waters, or _muriated alkaline_ waters, or simple _gaseous_

waters.

_Gastric Insufficiency, or Atonic Dyspepsia._—Now, as I have before

emphasised, this is the functional gastric disorder most commonly met

with in the gouty; the _hyperacidity_ is due to _excess of organic

acids_, and this, again, is the outcome of not excess, but _deficiency,

of HCL_. Now in cases of this nature with _subacidity_ of the gastric

juice numerous observers—Von Noorden, Dapper, Boas, and others—have

reported an increase in the secretion of hydrochloric acid following a

course of _muriated_ waters.

My own clinical experience of the _muriated_ waters of Llandrindod

abundantly confirms the results obtained by these authorities. The

enhanced digestive capacity of the patients is evidenced by relief of

epigastric pain and discomfort after meals and the decline of flatulent

distension. For, following the increased secretion of hydrochloric acid,

their intolerance of carbohydrates, due to subacidity, disappears,

and, fermentation no longer taking place, the over-distended walls of

the stomach gradually recover tone. It is customary for patients to

walk either during or after the consumption of water. But in decidedly

atonic conditions of the stomach with dilatation it is better, as

Ageron suggests, that such subjects lie down after drinking. Nor must

the beneficial effect of muriated waters on the associated constipation

be overlooked. The daily thorough evacuation of the intestinal canal

minimises or prevents toxic absorption, and at the same time depletes the

overloaded portal system.

The sources of blood contamination being removed, the general symptoms of

languor, drowsiness, and mental depression give place to a more cheerful

tone of mind. At the same time relaxation from business, an outdoor life,

and bracing air, with change of scene and society, doubtless contribute

to dissipate those feelings of supreme misery which are the bane of the

dyspeptic.

As to the foregoing remarks, I have but chosen Llandrindod as a type.

Thus some of the Harrogate waters are equally eligible for inclusion in

the _muriated_ as in the sulphurous group. Again, to these may be added

Builth Wells and Llangammarch Wells, the latter distinguished by its

content of chloride of barium, which is said to raise the blood pressure

and promote diuresis through its tonic action on the muscular coat of the

arteries. Woodhall Spa, too, calls for mention, the presence of iodides

and bromides in its muriated waters investing it, according to some,

with special alterative properties; lastly, the strong brine waters of

Droitwich, which find their special sphere in external application by

baths.

As to the Continental springs in this category, the most noteworthy are

Homburg, Kissingen, and Kreuznach, the last decidedly radio-active; while

of _thermal muriated_ waters Wiesbaden and Baden-Baden are the most

representative.

_Chronic Gastric Catarrh._—In this condition, not uncommon in the

gouty, and which Ewald aptly characterises as “the best fostered

and widest spread of this world’s ills,” a deficiency of gastric

secretion with impaired motility is constantly present. With this is

frequently correlated distension of the small intestine, due to abnormal

fermentative and putrefactive changes in the food.

Leaving aside the vexed question as to whether _muriated_ or saline

waters can be regarded as direct excitants of gastric secretion, it

cannot be doubted that the prolonged and systematic lavage of the

stomach, ridding it of viscid mucus and hastening the removal of retained

fermenting foodstuffs, must favour restoration of a healthy state of the

mucous membrane, and thus indirectly promote its secretory activities.

Again, inasmuch as the bulk of saline waters undergoes absorption in

the small intestine, the duodenal catarrh usually associated with

this condition is also markedly benefited by the removal of toxic

accumulations. Indeed, Niemeyer, discussing the therapeutic efficacy

of mineral waters in such states, goes so far as to remark that “the

results obtained are the most brilliant that have ever been attained

in medicine.” To achieve these salutary effects the “waters” must be

taken in amounts adequate to produce copious daily evacuation. For, if

insufficient to ensure this same, discomfort and distension ensue pending

the more tardy removal of the water by the kidneys.

Now, while in these cases the _muriated_ waters above alluded to are

suitable, the _muriated alkaline_ are equally eligible. Of these the

highest in repute are Royat, Chatel Guyon, and Saint Nectaire, and in

Germany Ems, Wildbad, Assmannshausen, and Wildungen.

Here a reservation in regard to Bickel’s researches, viz., it has been

found that in some cases of _chronic gastric catarrh_ in _robust_

subjects _simple alkaline_ springs, such as those of Vichy, Vals, and

Neuenahr, have, despite his experimental findings, proved actually

beneficial. On the other hand, these same waters have this cogent

objection, that long courses are apt to cause depression and emaciation,

and, moreover, may aggravate the gastric trouble. Worse still, these

_simple alkaline waters_ are more likely to produce an attack of _acute

gout_, whereas the _muriated alkaline_ varieties are free from these

objections.

_Hyperchlorhydria._—Bickel’s experiments led him to this further

conclusion, that in organic gastric disorders accompanied by _excess

of HCL_ the _simple alkaline_ and _sulphated alkaline_ group are to be

preferred to the _muriated_ waters.

Now, inasmuch as some authorities hold hyperchlorhydria as due to a

_chronic glandular gastritis_, it would seem that these should be given

a trial. Personally, I have no practical experience that I can draw

upon for substantiation or refutation as to the correctness of Bickel’s

assumption. Nor have I on this question been able to find any reference

in the literature or clinical findings emanating from these spas.

Much controversy, again, obtains in regard of the usage of _muriated_

waters in these cases. Formerly their employment was unreservedly

condemned, but more extended experience has modified this too dogmatic

attitude. Albeit, that the results obtained in hyperacidity (excess of

HCL) are uncertain is undeniable, and unfortunately it is impossible to

foretell whether or no any given case will derive benefit. The pronounced

nerve element in these cases, with probably other unknown factors, has

doubtless much to say to the conflicting clinical results.

But the experience of most of us will accord with that of Dapper and Von

Noorden, that _muriated_ waters, such as those of Homburg, Kissingen,

etc., often prove beneficial in cases of neurasthenia with hyperacidity.

On the other hand, it is equally true that some examples of apparently

the same nature derive no benefit, indeed are aggravated. But, according

to Von Noorden, such are in the minority.

Fortunately this secretion of an abnormally acid gastric juice is

relatively rare in the _gouty_. Being of the nature of a _secretory

neurosis_, it occurs most frequently in those of _neurotic_ or

_neurasthenic_ type. Now, holding the view that many cases of

neurasthenia are due primarily to toxic absorption, secondarily to

alimentary derangements, the beneficial effects observed are, I presume,

probably attributable in large part to the removal of toxic accumulations

through flushing. These deleterious substances not being absorbed in such

amounts as before, improvement in the general nerve tone ensues, in which

doubtless the secretory mechanisms of the digestive system participate.

But, as we have seen, these same _muriated_ waters prove most salutary

in precisely the opposite condition—_hypochlorhydria, or deficiency of

HCL_. That such a beneficial effect should ensue in diametrically opposed

states, viz., _hyper_- and _hypo_-acidity, gives point, I think, to the

contention that the action of _muriated_ waters on the digestive organs

must in great part be exerted not locally, but _indirectly_, that is,

secondarily to improvement of the general health and toning up of the

nervous system.

Indeed, the pronounced nerve element in these cases is probably the

explanation why, especially in instances palpably due to mental fatigue,

insomnia, etc., a course of baths or hydrotherapy at some simple thermal

spa, preferably those at certain altitudes, such as Buxton, Wielbad,

Gastein, Plombière, Ragatz, etc., often suffices without any internal

treatment.

_Functional Hepatic Disorders._—Fothergill held that some persons were

born with “congenitally incompetent livers,” an unwelcome legacy unduly

incident among those of gouty heritage. Now the intimate interdependence

of hepatic and gastro-intestinal disorders has long been recognised;

indeed, the swiftness with which retribution, in the shape of so-called

“biliousness,” overtakes those who fare not wisely, but too well, is

proverbial even among the laity.

Thus chronic hyperæmia of the liver, due to stasis in the portal area,

commonly ensues in those gouty subjects who eat and drink too much,

especially alcohol. The same Nemesis awaits those who lead too sedentary

a life, and in the train of chronic constipation develop such hepatic

congestion, with in some instances attacks of catarrhal jaundice.

As to treatment of these cases by mineral waters, a preference must

be given to _alkaline_, _sulphated alkaline_, or _muriated_ waters,

according to the special indications of individual cases. Thus suppose

the subject is stout and plethoric, and given perhaps to hæmorrhoids or

pruritis ani, then spas with _sulphated alkaline_ waters (Marienbad,

Karlsbad, etc.) may be recommended. But equally good results will follow

a course at home of _muriated_ waters, or _muriated sulphur_ waters, such

as Harrogate, Llanwyrtid, and Strathpeffer, etc.

Bearing in mind that functional hepatic disorders are in large part

secondary to gastro-intestinal derangements, it is probable that the

beneficial effect of the above types of waters on the liver is exerted

indirectly, though we must recollect that the salts of soda have a direct

stimulant action on the hepatic function.[66]

Given in adequate doses, they act as mild, unirritating laxatives,

the daily evacuations thus produced relieving hepatic congestion and

coincidently any tendency to portal engorgement. Through their dual

action of flushing the digestive canal and stimulating hepatic and

gastro-intestinal secretory activities, we find the explanation of the

decided benefit that follows their use in gastric catarrhs, especially of

alcoholic origin, also in catarrhal jaundice, incipient cirrhosis of the

liver, and so-called abdominal venosity.

As we know, Sir Lauder Brunton long since pointed out that the ingestion

of saline mineral waters tends to counteract any tendency to catarrh

of the biliary passages, the biliary secretion tending to become less

viscid; consequently the passage of gall-sand is promoted. Some, like

Hans Kehr, of Holberstadt, advise a course of saline waters _after_

operations for the removal of gall-stones; others advocate their

employment _before_ surgical intervention. It is obvious, however, that

their range of usefulness in this affection must be limited and is

largely to be attributed to their power of mitigating inflammatory or

catarrhal changes in the gall bladder and its related ducts.

_Intestinal Derangements._—Constipation is, as is well known, the _bête

noire_ of the gouty, and, while the basal indications of its therapy have

to be carefully ascertained in every individual, still much may be done

by a properly chosen and adequately supervised course of spa treatment.

This, of course, entails revision of the diet and habits, notably in

regard to exercise; in some of sedentary habit a mere change of air

to a more bracing climate, with its associated increase of exercise,

may suffice; in others of stout plethoric type a visit to one of the

sulphated alkaline spas will be of benefit; while in weaker subjects of

the lean kind muriated waters will be more suitable.

In many the habitual constipation is due to a catarrhal condition of

the intestine. Trautner, as we know, considers that gout originates in

a mucous colitis. In France the gaseous muriated waters of Chatel Guyon

are in great vogue for chronic catarrhal conditions of the intestines,

especially those associated with abdominal plethora and constipation.

Indeed, because of its success in these cases, it is sometimes called the

French Kissingen.

On the other hand, the Plombières Spa is the one that _par excellence_

devotes itself to the treatment of mucous colitis by a combination of

(1) intestinal douches, (2) sedative warm baths, and (3) “under-water”

douches directed against the abdomen. Treatment by the Plombières

method is now available at most English spas, and, while I can speak

highly of its benefits, I think perhaps there is sometimes a tendency to

resort to it after a routine fashion irrespective of the presence of any

special indications for its usage. The after-results in some cases are

not enviable, and recently a distinguished surgeon informed me that he

had met with instances in which ill-advised and prolonged usage of such

irrigation resulted in an atonic condition of the colon.

ASSOCIATED MORBID CONDITIONS

_Glycosuria._—The more chronic and benign forms met with in gout

frequently derive benefit from a course of mineral waters, though,

of course, revision of the diet and regimen in general are essential

concomitants thereof. Indeed, the high reputation achieved by certain

Continental spas—Karlsbad, Vichy, Neuenahr, etc.—in this disorder is in

large part due to the care and attention bestowed on these the basal

indications.

In the gouty obese, with a tendency to piles and abdominal plethora, the

_sulphated alkaline_ and _simple alkaline_ waters, such as Karlsbad,

Vichy, Neuenahr, Brides-les-Bains, etc., are suitable, and in this

country the _muriated sulphurous_ waters of Harrogate and Llandrindod.

In some of the gouty obese their bouts of glycosuria sometimes

alternate with attacks of uric acid gravel, and not infrequently there

is also present a slight degree of albuminuria. In these cases the

_earthy or calcareous_ waters enjoy a considerable reputation, notably

Contrexéville, and not a few with uric acid gravel and slight albuminuria

resort to Wildungen.

I have before alluded to the beneficial effects in glycosuria of Bath

waters, which, like Contrexéville and Wildungen, have an earthy or

calcareous content. For the less robust and lean type of glycosuric

Sir Hermann Weber recommends “simple thermal baths, such as can be

obtained at many resorts of moderate elevation (Gastein, Wildbad,

Buxton, Schlangenbad, and Ragatz).” As an alternative, he states that

“the internal use of muriated alkaline or simple alkaline waters (Vichy,

Neuenahr, Obersalzbrunn, Royat, La Bourboule), in association with

thermal baths or alone, may often be recommended.”

_Oxaluria._—This condition, like glycosuria, is often met with in the

gouty. It is of course often due to faulty diet, but in many instances

there is a strong nerve element in the case. In the former instance

dietetic restrictions are the basal indication. In these cases, if there

be constipation, a visit to the _muriated_ springs in this country

or to Kissingen, Homburg, etc., is advisable. Otherwise, _alkaline_

springs, _i.e._, Vichy, or _alkaline earthy_ springs, such as Vittel,

Contrexéville, or Martigny-les-Bains, may be given the preference. For

those instances in which the nerve element is predominant the character

of the mineral waters is quite subsidiary compared with the all-important

point of procuring the subject freedom from worry.

_Gouty Phlebitis._—It is believed that gaseous muriated waters, both

internally and in the form of baths, are useful in counteracting any

tendency to phlebitis. Obviously, if there be any symptom or sign of

existing phlebitis, any such procedure would be fraught with risk. Still

patients who have had phlebitis frequently resort to such spas, notably

Bagnoles-de-l’Orme, where the resident physicians have made a special

study of the constitutional tendencies to chronic phlebitis. The waters

are but weakly mineralised, and may be classed in the simple thermal

group (81°-84° F.).

_Respiratory Disorders._—While, as I have said, I deprecate any notion

of specific gouty types of bronchitis, asthma, etc., there is no doubt

that gouty subjects, like many others, are prone to bronchial affections,

and for such mineral water treatment at a favourable season of the year,

is equally beneficial. In gouty bronchitics of plethoric type, courses

of sulphated alkaline waters will often do much to relieve the symptoms.

Again, many sulphur, muriated alkaline, and muriated spas, have achieved

a great reputation in the same sphere, _e.g._, Ems, Royat, Eaux-Bonnes,

Baden-Baden, and Soden. Nor need we go outside our own country, for many

of our mountain health resorts are in the summer months equally eligible

for treatment of these disorders of the respiratory system.

_Fibrositis._—Adequately to describe all the methods, internal and

external, in vogue at spas for the treatment of, _e.g._, chronic lumbago

and sciatica, would be quite futile in the space at my command. I have

the less compunction in being unusually brief inasmuch as Bassett Jones

and I have dealt exhaustively with the subject in our work on fibrositis.

The groundwork of successful treatment will rest on the application of

the general principles in force for the treatment of the underlying gout.

They will, of course, include internal and external treatment by simple

thermal waters, the thermal muriated and thermal sulphurous waters, etc.

Frequently, too, cold muriated and other waters artificially heated are

invoked for this dual purpose.

The benefits of external treatment by douches of varying character will

depend on the measure of discrimination exercised in adapting their

application to suit the individual necessities of the case. But I would

here lodge a plea against the far too great frequency with which such

cases are sent to spas during the acute phases, whereas it is only the

subacute or chronic forms that are eligible for treatment by hydrotherapy.

_Gouty Eczema._—The climatic suitability of the spa is of primary

importance, and while, as a rule, cold, damp and windy localities are

to be avoided, still personal idiosyncrasy plays a large part in the

decision, some cases of eczema being aggravated by cold, others by heat

and sunlight.

The spa treatment of gouty eczema has for its aim the correction of the

constitutional taint by the internal exhibition of mineral waters in

conjunction with baths. To this end, the eliminative effects of courses

of alkaline (Vichy, Vals), muriated (Llandrindod), sulphurous (Harrogate,

Strathpeffer, Llanwyrtid), or muriated sulphurous waters (Uriage,

Aix-la-Chapelle, etc.), are often invoked with marked benefit.

Again, the thermal muriated alkaline waters of Royat and the arsenical

springs of La Bourboule have acquired a great reputation in gouty eczema,

and in obstinate but non-pruriginous types the prolonged tepid baths in

vogue at Loèche-les-Bains, in Switzerland.

In many instances of senile or atrophic type a course during the summer

of simple thermal baths is often beneficial. Buxton is suitable, also

Wildbad, Schlangenbad, Ragatz, etc. Lastly, in eczema of seborrhœic

type thermal sulphurous waters, _e.g._, Schinznach, Aix-les-Bains,

Bagnères-de-Luchon, etc., are highly commended.

_Uric Acid Gravel._—Though, as before stated, there is no specific

connection between this disorder and gout, still the gouty no more than

others are immune therefrom. For the stout, plethoric, and constipated,

sulphated and sulphated alkaline springs are indicated. But if, on the

other hand, there is a tendency to diarrhœa, these aperient waters must

be renounced in favour of simple alkaline springs. In those of less

robust type the simple thermal or earthy waters, notably Contrexéville

and Wildungen, are to be preferred, and failing these, the muriated

waters.

_Arterio-sclerosis._—It is hardly necessary to say that in all but the

slightest forms high altitudes are contra-indicated. In these less

advanced cases, if the subject be stout and plethoric, the sulphated

alkaline waters (Karlsbad, Marienbad, etc.) are useful; while in thin

persons the muriated waters are more suitable.

In more advanced cases we may during summer advocate a course of

treatment at some simple thermal spa, such as Buxton, and many of these

cases do well at Bath during the spring, or they may be sent to Bourbon

Lancy, which has been termed the French rival to Nauheim, because of the

excellent results obtained in cases of raised blood pressure.

_Chronic Nephritis._—Clearly in these cases a quiet life, without mental

worry, gentle and not excessive exercise, with residence in an equable

climate, are the primary indications. In the early stage, when the

patient’s condition is good, the tension not high, and the quantity of

albumen small, the subjects derive much benefit from an annual visit

to certain mineral springs. Not that mineral waters have any curative

influence; they merely help the interstitial circulation and promote

flushing.

Of mineral waters the _simple thermal_ or the _weak alkaline_ are

generally considered the most eligible, _e.g._, Vichy, which is useful

also in cases of combined albuminuria and glycosuria. In cases with

cardiac dilatation care should be taken not to prescribe mineral waters

in excessive amount. If complicated by anæmia, chalybeate waters,

according to Weber, are “not rarely useful.”

Bain and Edgecombe, discussing gouty albuminuria, state that the magnesia

water of Harrogate, in combination with the old sulphur, has a marked

effect in reducing the absolute amount of albumen in the urine, _e.g._,

from one-fourth by volume to a mere trace. They add, that if the specific

gravity of the urine be low chalybeate water is indicated with, if

necessary, a morning aperient draught. If glycosuria and albuminuria

co-exist, the “sulphur waters may be tried tentatively” as the specific

gravity does not help us in these cases. “When in doubt, it is safer to

give an iron water and trust to diet and baths for a diminution in the

excretion of these substances.” Not a few of these cases find their way

to Bath and Buxton, often for relief of their increased arterial tension,

and the experience of most is that in the more robust types a course of

Aix massage is advantageous, while for others more advanced in years

baths after the Bourbon Lancy method.

CONCLUDING REMARKS ON SPA TREATMENT

It is well that the potency and complexity of spa treatment be realised,

involving as it does not only drinking or internal treatment, but

also _balneotherapy_, _electro-therapy_, and all the other accessory

therapeutic methods now at command. With all these powerful weapons to

hand, it is obvious that their use demands a corresponding degree of

discrimination, this even in cases otherwise suitable, and here a word

as to the types of gout most suitable for the _internal_ exhibition of

mineral waters.

In this matter the rules laid down for hydrotherapy, or the _external_

use of waters, are in the main applicable. In other words, _acute cases

of gout are always ineligible_, as likewise those instances in which

an attack appears imminent or those in which recovery from an _acute_

paroxysm is barely accomplished. On the other hand, mineral waters are

indicated in _chronic_ gout and in the _inter-paroxysmal_ periods that

mark the _early_ stages of the disorder. Indeed, I know of no other

treatment that is as effectual, and, with Sir William Roberts, “I do not

think, therefore, that gouty patients, if they can afford the time and

expense, should forego the advantages of the time-honoured practice of a

visit to a mineral spring.”

But, to attain the best results of spa treatment, not only should the

cases be suitable, but they should be despatched at the right _season_.

Even in spas that are open all the year round we should try to select

the most congenial month. Thus, if the subject is intolerant of heat, we

should not advise him, say, to go to Bath in July or August, or, for that

matter, during the hottest summer months to Aix-les-Bains, Baden-Baden,

Wiesbaden, Neuenahr, etc. If he has to take his course at this period of

the year, and a thermal spring is indicated, Buxton will be more suitable

than Bath, and we have a large choice of other spas in more bracing

localities, such as Harrogate, Llandrindod, Strathpeffer. In short, some

discrimination must be exercised. Again, if a course be indicated in the

winter, we should favour those spas where the hotels are in proximity

to the springs, so as to obviate unnecessary exposure, _e.g._, Bath,

Wiesbaden, Helouan, etc.

As to _duration_ of a course, there is, I think, in many spas a too

great tendency to be dominated by tradition. Not only is the duration

of the cure arbitrarily fixed, but, still worse, the drinking of the

waters, the bathing, and even the dietaries are frequently in danger of

becoming stereotyped, with, as a consequence, a lack of that eclecticism

necessary in the best interests of individual cases. A certain amount

of routine is unavoidable, and has this advantage, that persons find it

easier to submit to irksome restrictions when they see others conforming

thereto. But even so there is ample scope for such modifications as may

be required, and upon their adoption the success of spa treatment mainly

depends.

If arbitrary rules in respect of drinking, bathing, etc., are to be

deprecated, the same applies with unvarying fixity to the duration of

a cure for all cases. Generally speaking, three to four weeks is the

average stay at spas. But obviously it should be varied to suit the

patient’s condition, and in many instances of chronic gout it may with

advantage be extended to six or eight weeks.

Again, I think perhaps in this country the advantages of an _after-cure_

are insufficiently realised. In this respect our Continental brethren

set us an example, attaching the greatest importance as they do to

an after-cure, especially after a course of laxative waters, _e.g._,

Karlsbad, Marienbad, and Kissingen. Certainly to plunge forthwith into

work immediately after a cure leads but too often to another breakdown

and the undoing of any advantages that may have been reaped. Of late I

have noted, especially in business men, a tendency to interrupt even

their course by travelling considerable distances on _non-bathing_ days

to attend to their affairs. The folly of this is obvious, and the results

are almost invariably unsatisfactory. Indeed, in these all too strenuous

days one almost despairs of _after-cures_, for it is difficult enough

oftentimes to prevail on people to stay even for their course of three

weeks, and frequently one is asked to conduct their treatment after a

more intensive fashion, and so abridge it to a fortnight or even a week!

As to the nature and site of the resorts suitable for an _after-cure_

it is impossible to lay down general rules, as individual peculiarities

have to be considered. But the physician who prescribes such ought, as

Sir Hermann Weber remarks, “to be acquainted with the nature of the

locality recommended, if possible by personal visits, and the reports of

thoroughly judicious people.” For, as he rightly says, there are numerous

places in the British Isles perfectly suitable for an after-cure, to

mention but a few in England, Ilkley, Ben Rhydding, Malvern, Haslemere,

Church Stretton, Crowborough; in Scotland, Braemar, Ballater, etc.; and

in Wales, Llanberis, Llangollen, etc.

SPAS FROM A NATIONAL ASPECT

But brief reflection on the foregoing considerations suffices to make it

clear that the various spas and health resorts with which this country,

through Nature’s beneficence, has been so bountifully endowed, are but

members one of another, in short _complementary_, not antagonistic, as

I fear is sometimes thought. This latter is a view to be discarded in

favour of a more rational conception of these various centres from their

collective aspect as integral parts of a therapeutic whole.

Now what, in a word, is the outstanding feature of our national life

to-day? _Co-operation_—a veritable furore of national and international

effort such as the world has never seen. Spas, too, must fall in line

with the national trend, must organise and co-operate, if they would

play their full _rôle_ in the drama of reconstruction. Now, from the

point of view of the State, the true objective in therapeutics is the

achievement and maintenance of national efficiency—the production of

healthy citizens, sound economic units. This then is the high purpose

with which those responsible for spas must ever be animated—an aim only

to be attained by their whole-hearted co-operation one with the other.

The lay custodians, too, of spas must increasingly realise that they

do but hold in trust their healing springs to be safeguarded in the

interests of the community. Mineral waters, like coal, issue from the

bowels of the earth. Both are _natural_ products; both are _national_

assets. I doubt not that the growing movement for effectual popular

control so rapidly obtaining a grip over the political and economic life

of the nation will shortly be extended to our spas, with, as its outcome,

their _unification_ and _co-ordination_ under the controlling influence

of a central body of experts vested with plenary powers to inspect,

control, and inspire the development of these hydrotherapeutic centres.

“Salus populi suprema est lex.”

FOOTNOTES

[1] Ewart, discussing the antiquity of gout, observes that it is

“certainly as ancient as civilisation,” and as far as we can identify

them in the accounts handed down from remote ages, the etiology, the

leading symptoms, the outward characters of the _articular_ gout of the

ancients were practically the same as belong to gout in our own times!

But of its relative prevalence in antiquity we have no means of judging.

Continuing, he holds that “the ultimate lesions of gouty arthritis and

its pathology are presumably as immutable as those of osteoarthritis.”

This may be so, but such objective evidence as we possess certainly

points to the greater antiquity of osteoarthritis as the following

quotation from our work, “Arthritis Deformans,” testifies:—

“During the course of some excavations undertaken by the Survey

Department of the Egyptian Government in that tract of Nubia lying

immediately south of the First Cataract, over 6,000 bodies were brought

to light, comprising among them representatives of all periods from

early pre-dynastic times down to the fifth century after Christ. As the

result of their examination of this vast accumulation of human _débris_,

Professor Elliot Smith, in the Nubian Survey Bulletin, states that “The

disease which shows itself with by far the greatest frequency in the

bodies of all periods is rheumatoid arthritis” (Osteoarthritis).

[2] 920 (S. Eng. Leg.), “There cam a goute In is knee, of Anguische

gret.... So longue, that is kneo to-swal.”

1310 (In Wright Lyric), “A goute me hath ygreythed so, Ant other eveles

monye mo.”

1377 (Langl., P. Pl.), “He ... gyued me in goutes, I may noughte go at

large.”

1400 (Lanfranc’s Cirurg.), “A man that hath arteticam, that is as myche

to seie as a goute.”

1450 (M.E. Med. Bk., Heinrich), “Here wyth anoynte the goutes.”

1566 (J. Alday, tr. Baoystuau’s Theat. World), “Their legges full of

gouts.”

1579 (Langham, Gard. Health, 1633), “For all goutes, seethe Leekes and

Otemeale with sheepes tallow, and apply them hot.”

1590 (Spenser, F. Q.), “And eke in foote and hand A grievous gout

tormented him full sore.”

1697 (Dryden, Virg. Georg.), “From Winter keep Well fodder’d in the

Stalls, they tender Sheep.... That free from Gouts thou mayst preserve

thy Care.”

1704 (Fuller, Med. Gymn.), “There have been some Gouts ... which nothing

could remove but a very low Diet.”

1732 (Pope, Ess. Man.), “So, when small humours gather to a gout The

Doctor fancies he has driv’n ’em out.”

1822 (Ld. Eldon, in Twiss Life), “I found the King in bed yesterday. He

has had a pretty severe gout.”—_New English Dictionary, Oxford_, 1901.

(_Ed. Sir James Murrary._)

[3] Pitt, in one of his last letters to the Marquess Wellesley, deplores

his slow recovery from severe attacks of gout with which, by the bye, the

statesman Fox was likewise affected.

[4] Both Norman Moore and Bowlby subsequently upheld Ord’s view that

uratic deposits only occur in tissues already degenerated. “Ebstein’s

view has been modified by Von Noorden, who holds that a special ferment

leads to the tissue change, to which the deposit of the urate is

secondary.”

[5] _Physiognomy of the Goutily Disposed._—Taking the principles as laid

down by Laycock, the peculiarities of those thus affected fall under the

head of the sanguine arthritic diathesis. (That careful observer did

not fail to note the modifying influences of gout upon struma and other

cachexia.) Thus may be compared the physiognomy of the diathesis and its

associated cachexia (developed in time):—

Blood-vessels numerous; heart large and powerful; blood-corpuscles

numerous; skin over malar bones highly vascular (florid complexion);

skin fair, firm, oleaginous, perspirable; eyes blue; hair thick, not

falling easily; teeth massive, well-enamelled, regular, even, undecayed

in advanced life; malar bones flattened; head symmetrical; nasal bones

well-formed, nose aquiline or of mixed form; lower jaw massive; lips

symmetrical.

_Form._—Figure for the most part tall; thorax broad at the summit; ribs

well-curved; abdomen full; muscles firm, large; limbs large, robust; gait

erect, well-poised. _Nutrition_ active; digestion vigorous; appetite

great for animal food and alcoholic stimuli. _Respiration_ deliberate,

deep; circulation vigorous; animal heat abundant; locomotion active;

aptitude for exercise and outdoor amusements. _Reproductive_ powers

active; innervation abundant, the mental powers vigorous and enduring.

_Physiognomy of the Sanguine Gouty Cachexia._—Blood-vessels largely

developed over the malar bones and varicose; skin oily, yellow from

subcutaneous deposit of fat; hair thick and white; teeth numerous,

discoloured, crusted with tartar; lips bluish, nose reddish,

hypertrophied; arcus senilis; abdomen pendulous; limbs thick; joints

nodose; nodosities on the ends of the fingers, lobes of ears, fascia of

muscles, and tendons; respiration hurried, wheezing; pulse intermittent,

irregular; stomach flatulent; digestion acid; urine loaded with lithates;

temper irritable; mind sometimes enfeebled.

The local diseases of the arthritic cachexia are principally seen

in adult males past the age of forty-five. They consist especially

in chronic inflammation of the muscular and articular tissues; in

calcification of the basilar and coronary arteries, and of the cardiac

valves. These changes give rise to hæmorrhagic apoplexy, angina pectoris,

cardiac hypertrophy and dilation; and to secondary pulmonary affections,

as emphysema, pulmonary apoplexy, and asthma. Irritation of the mucous

surfaces may give rise to nephritis, pharyngeal and laryngeal coughs, and

diarrhœa.—_Med. Observation and Research_, 2nd edition, pp. 96-98.

[6] According to Fischer the protein molecule can be split up into

amino-acids, di-amino-acids, aromatic-amino-acids, nitrogenous

derivatives of the benzene ring, pyrimidine bases, pyrrolidine

derivatives, cystin, and ammonia. During proteolysis the amino-acids

exist in groups, _e.g._, glycine and leucine (glycyl-leucine), two

leucine radicles (alanyl-leucine), etc.—which combinations Fischer

termed polypeptides, and some of which he has been able to produce

synthetically. Furthermore, Fischer proved that nitrogen equilibrium can

be maintained in animals by feeding them upon these polypeptide products

of proteolytic digestion which no longer gives the biuret reaction. The

derivation of amino-acids, etc., from peptone is the outcome of the

action of a special intestinal ferment—_erepsin_. This enzyme is found

not only in the alimentary tract, but in all tissues of the body, its

action being especially developed in the renal tissues.

[7] Glycocoll in solution dissociates more H-ions than OH-ions. In the

presence of alkalies this acid character is more marked, so that it tends

to throw the uric acid salts out of solution. The inhibitory influence of

the urea upon the precipitation of uric acid from solutions is due to its

basic nature.

[8] Recent researches by S. R. Benedict show that uric acid, in the blood

of most mammals, exists in combination, but not in that of the bird.

Fresh ox-blood (Folin method) contains only 0·30005 gram, free uric acid

per 100 grams of blood. But after boiling the protein-free blood filtrate

with hydrochloric acid the uric acid content was about ten times as high.

Moreover, this same augmented uric acid content was found to exist “in

whole blood that had been allowed to stand for some time, indicating

that the _uric acid compound_ can be split by means of an _enzyme_.” The

compound exists, not in the plasma, but in the _corpuscles_. MacLeod, to

whose work on bio-chemistry we are indebted, remarks that “It is of some

significance that after thus setting free the uric acid, there should be

about 50 per cent. more of it present in the blood of the ox than in that

of the bird, where most exists in a free state in the serum, although the

urine of the ox contains only the smallest trace of uric acid, and that

of the blood is loaded with it. Investigation of the condition of uric

acid in human blood is at present in progress.”

[9] According to Sir William Roberts, there are three compounds of uric

acid (H₂U)—the neutral urate, M₂U, in which the metal replaces all the

displaceable hydrogen, the biurate, MHU, in which half the displaceable

hydrogen is replaced by the metal, and the quadriurate H₂UMHU, in which

one-fourth of the displaceable hydrogen of two molecules is replaced by

the metal.

Hutchison and Tidy suggest “that if Roberts’ salt be considered as NaHU.

MH₂U instead of Na. HU, his hypothesis remains unaltered, whilst much

of the criticism urged against it is nullified. The possibility of such

a substance is shown by the existence of the compound LiHU₄HU. Roberts’

theory, or such a modification, is not inconsistent with Von Noorden’s

views if these intermediate salts be regarded as within the tabernacle of

organic combinations from which the kidneys can split off and excrete the

uric acid.”

[10] “If further investigations yield facts which sustain such an idea,

it may be more easy to comprehend the types of the demands which are made

upon the renal functions.... One of the next stages of research will be

the determination of the behaviour of renal tissue to the various purin

isomers. This may lead on to the identification of the types of nuclein

derivations and their precise cellular origin. Perhaps this in turn may

reveal whether there are any differences between the nucleotides of

normal and gouty tissues. To this end progress in the technics of the

cultivation of tissues _in vitro_ may furnish a means for the elucidation

of some of these questions.”—_Walker Hall._

[11] As a further illustration of the differences which may exist in the

purin metabolism in different kinds of animals, in man and the anthropoid

apes the quantity of purin bases in the urine is small in proportion

to the quantity of uric acid. In the pig, which is included among the

animals that form allantoin from uric acid, the purin bases exceed

the uric acid in amount, whereas in the dog, which likewise excretes

allantoin, the purin bases exist in very small amount compared with the

uric acid.—_Stewart’s_ “_Manual of Physiology_.”

[12] The findings of Soetbeer and Ibrahim also indicate that 50 per cent.

of the exogenous purin bodies undergo oxidation to uric acid, and 50 per

cent. undergo further disruption and are excreted as urea or intermediate

bodies.

[13] The subject of the experiments—a healthy male (M. S. D.), 22 years

of age and 58 kilos in weight—was placed for over six months upon a

meat-free low protein diet, free also from purin-containing beverages.

This with the exception of a few meals in the holidays, during which

a small amount of meat was taken. “No attempt was made to secure a

quantitative uniformity of the diet.” On the evening preceding the day

of an experiment a light supper was eaten, and no further food was

ingested until the completion of the day’s experiment, save the substance

whose influence on uric acid excretion was to be studied. The urine was

collected hourly, 200 c.c. of water being ingested hourly throughout the

experimental period.—“_Uric Add Metabolism_,” 11—_H. B. Lewis, M. S.

Dunn, and E. A. Doisy, “Journal of Biological Chemistry,” 1918._

Two other men also served as subjects. Many of the experiments were

duplicated, and similar results obtained with these other subjects, but

inasmuch as the experiments with M. S. D. were more comprehensive and

extended over a longer period of time, the data of these experiments

alone are presented.

[14] Quoting from the same article, _Journal of Biological Chemistry_,

1918, by Lewis, Dunn and Doisy, these authorities observe that—_re_

glycocoll and alanine, Lusk concluded that “the chemical stimulation

of protoplasm which is responsible for the phenomena of increased heat

production (specific dynamic action) results from the action of their

intermediary products, glycocollic and lactic acids, rather than from

the amino-acids themselves. The phenomena of the stimulation of uric

acid metabolism by amino-acids run parallel to those of the specific

dynamic action of the amino-acids (except in the case of the dicarboxylic

amino-acids), and it is possible that the same chemical factors are

responsible for both.”

[15]

C₅H₄N₄O₃ + O + H₂O------>C₄H₆N₄O₃ + CO₂

Uric acid. Uricase. Allantoin.

[16] Experimenting on a Dalmatian coach-hound, Gideon Wells was able to

confirm Benedict’s observation that it excretes large quantities of uric

acid. But inasmuch as the liver of this same dog was able to destroy uric

acid _in vitro_, the inference is that the presence of uric acid in the

urine of the Dalmatian is not attributable to the _absence of uricase in

its tissues_. “The kidney did not exhibit uricolytic activity. Neither

the liver nor spleen converted xanthine into uric acid, but the liver

deaminised both guanine and adenine.”—_Journal of Biological Chemistry_,

1918.

[17] Wells, in his “Chemical Pathology,” observes that the amount of uric

acid that appears in the urine depends upon a variety of factors which

may be summarised as follows:—

(1) The amount of purin bodies taken in the food upon which

chiefly depends the amount of exogenous uric acid.

(2) The amount of destruction of tissue nucleo-proteins.

(3) The amount of purin bases formed in the muscle tissue.

(4) The amount of conversion of purin bases into the uric acid.

(5) The amount of destruction of uric acid, if any, occurring

in the body.

(6) Possibly upon the capacity of the tissues to synthesize

uric acid; and in case such power to synthesize uric acid

exists upon the presence of the precursors of uric acid in the

body.

(7) The retention of uric acid in the blood and tissues.

(8) The power of the kidney to excrete uric acid.

(9) The solubility of uric acid in urine—dependent upon the

amount of neutral phosphates present, the temperature, reaction

and concentration thereof.

[18] EFFECT OF ATOPHAN ON EXOGENOUS PURINS. (McLester, in “Archives of

Internal Medicine.”)

-----+--------------------------+--------+------------------------------

| | | Twenty-four Hour Urine.

| | Blood +-------+-------+-------+------

Date.| R. E. |Mg. U in| Amt. | | NH. |

| |100 Gm. | c.c. |U. Gm. |Gm. N. |N. Gm.

-----+--------------------------+--------+-------+-------+-------+------

5/28 | ---- | 2·9 | 1,150 | ·46 | ·58 |10·26

5/29 |7 a.m.: 500 grams thymus. | | | | |

| 2 p.m.: Blood | 3·2 | 900 | ·66 | ·69 |10·96

5/31 |7 a.m.: 500 grams thymus. | | | | |

| 9 a.m.: Atophan, 2 p.m.:| | | | |

| Blood | 1·1 | 1,280 | ·75 | ·76 |11·16

-----+--------------------------+--------+-------+-------+-------+------

[19] Walker Hall states that: “Taking the total volume of blood at three

and a half litres, and the volume passing through the lungs as four

and a half litres per minute, and through the kidneys as one litre per

minute, and the solubility of lactim-urate as 0·1 grm. per 4,000 c.c.

of blood, it would seem that the average daily output of 0·5 grm. could

be suspended in the quantity of blood passing through the lungs in five

minutes or through the kidneys in twenty minutes normal.”

[20] Criticising the colorimetric method on the ground that “different

workers obtain on the same blood samples results which vary

considerably,” L. J. Curtman and A. Lehrman have devised a new volumetric

method for the determination of uric acid in blood. The following is the

summary of their researches:—

(1) An experimental study of a number of metallic salts as precipitants

for uric acid in a solution alkaline with sodium carbonate was made. The

results showed that _nickel_ is the best of those tried.

(2) A 0·0004 N iodine solution was found suitable for the estimation of

small amounts of uric acid provided certain conditions are adhered to.

(3) Based upon the above considerations, a new method has been developed

for the determination of uric acid in blood, the chief features of which

are (_a_) the precipitation of the uric acid by means of nickel acetate

in a solution alkaline with sodium carbonate. (_b_) The estimation of the

uric acid in the precipitate by means of a dilute solution of iodine.

(4) The method was applied with good results to aqueous solutions of uric

acid as well as to blood serum to which known amounts of uric acid were

added.

(5) Low and inconsistent results were obtained when the method was

applied to sheep’s blood to which known amounts of uric acid were added.

This was shown to be due to the inadequacy of the procedure generally

employed, for the coagulation and preliminary treatment of the blood.

The colorimetric method when used in the analysis of samples of the same

blood also gave low and inconsistent results for the same reason.

(6) Comparison tests show that the volumetric method is fully as accurate

as the colorimetric method, and possesses the advantage of requiring no

special apparatus.

[21] URIC ACID ESTIMATION IN NORMAL INDIVIDUALS

(McLester, “Archives of Internal Medicine.”)

_Milligrams Uric Acid in 100 grams Blood._

J. C. 0·5

H. D. 0·6

M. D. 0·6

A. B. 0·8

R. C. 0·9

H. D. 0·9

J. G. 0·0

S. M. 1·1

R. D. 1·3

L. S. 1·4

L. H. 1·7

R. O. 2·1

H. H. 2·5

J. M. 2·5

R. E. 2·9

URIC ACID OF BLOOD IN DISEASE. (McLester, “Archives of Internal

Medicine.”)

_Milligrams in 100 grams Blood._

Mitral lesion 0·5

Rheumatic fever 0·6

Acute syphilis 0·8

Chronic tuberculous pleurisy 0·8

Pneumonia 1·2

Pneumonia 1·3

Sciatica 1·3

Typhoid fever 1·4

Ulcer of stomach 1·5

Pneumonia 1·6

Amœbic dysentery 1·6

Neurasthenia (?) 1·7

Acute tuberculous pleurisy 1·7

Chronic interstitial nephritis 1·8

Malaria 1·8

Pneumonia 1·9

Uremia 2·1

Polycythemia 2·2

Graves’ disease 2·5

Pneumonia 2·7

Gout 3·3

Arterial hypertension 3·3

Intermittent gastric supersecretion 3·7

Gout 4·5

[22] However, as Walker Hall reminds us, Taylor, writing in 1912,

stated, “That the margin of safety with regard to renal excretion is an

exceedingly narrow one, that the kidney excretes uric acid slowly, and

that its powers are soon overstepped.”

[23] Magnus Levy and McClure have also noted that the excretion of

exogenous purin is not invariably retarded or diminished.

[24] When experimentally injected, the urates are absorbed slowly by

phagocytic leucocytes and giant cells.—_Gideon Wells._

[25] Because the gouty tophi do not suppurate, even when ulcerated,

through the skin, it has been suggested that the urates have antiseptic

properties. Bendix (_Zeit. klin. Med._, 1902 (44), 165), however, could

not demonstrate such antiseptic properties experimentally.—_Gideon Wells._

[26] Levinthal, in a personal experiment, injected half a gram of xanthin

dissolved in piperazine into his cubital vein. A few days later, after a

moderate strain upon the limbs through dancing, he was suddenly seized

with a fairly acute painful attack in one of his knees, attended with

some swelling and local heat.

[27] “Tophi sometimes precede by some years ... the development

of gouty attacks in joints. The same is true also of auricular

tophi.”—_Duckworth_: “_A Treatise on Gout_.”

[28] “While, however, tophaceous concretions generally show themselves

after attacks of articular gout, cases occur, as I have already told you,

in which the secretion of calcareous matter takes place irrespective of

any arthritic attack. This sort of _cutaneous gravel_, if I may employ a

comparison based on the great analogy between the composition of urinary

gravel and tophaceous concretions, gravel of the skin, constitutes the

sole manifestation of the diathesis, and is accompanied merely by a

slight feeling of pain, of pricking unattended by any disturbance of the

general health.”—_Trousseau’s_ “_Clinical Medicine_.”

[29] _Redness_ of the skin overlying a developing tophus is not

invariable. In a case recently under my care, the dorsum of the

mid-phalangeal joints was the seat of small soft localised swellings.

The superjacent skin was unchanged in colour. Aspiration of the contents

by a hypodermic syringe disclosed the presence of a turbid white fluid,

which, when microscopically examined, was found loaded with the acicular

crystals of sodium biurate.

[30] “Quod in omnibus podagricorum paroxysmis solemne est, insignior

intumescentia venerum membro vexato intertextarum se in conspectu

dat.”—_Sydenham._

[31] Sydenham’s classical description: “Towards the end of January or

the beginning of February suddenly, and with scarcely any premonitory

feelings, the disease breaks out. Its only forerunner is indigestion

and crudity of the stomach, which troubles the patient for some weeks

previous to the attack. His body also feels swollen, heavy, and

windy—symptoms which increase from day to day until the fit breaks out.

But a few days before this torpor comes on, and a feeling of flatus along

the legs and thighs. Besides this, there is a spasmodic affection, whilst

the day before the fit the appetite is unnaturally hearty. The victim

goes to bed in good health and sleeps. About two o’clock in the morning

he is awakened by a severe pain, generally in the great toe, more rarely

in the heel, ankle, or instep. This pain is like that of a dislocation

of the bones of these parts, and is accompanied by a sensation as of

chilly water poured over the membranes of the suffering joint. Then

follow chills and shivers and a little fever. The pain, which was at

first moderate, becomes gradually more intense, and while it increases

the chills and shivers die out. Every hour that passes finds it greater,

until at length at night-time it reaches its worst intensity, and

insinuates itself with most exquisite cruelty among the numerous small

bones of the tarsus and metatarsus, in the ligaments of which it is

lurking. Now it is a violent stretching and tearing of the ligaments, now

it is gnawing pain, and now a pressure and tightening. So exquisite and

lively meanwhile is the feeling of the part affected that it cannot bear

the weight of the bedclothes nor the jar of a person walking in the room.

Hence the night is passed in torture and a restless rolling first to one

side, then to the other, of the suffering limb, with perpetual change of

posture, the tossing about of the body being as incessant as the pain of

the tortured joint, and being at its worst as the fit is coming on. Hence

the vain efforts by change of posture, both in the body and the limb

affected, to obtain an abatement of the pain.

“This comes only towards the second or third hour of the morning (a

whole day and night after the first outbreak of the fit), such time

being necessary for the moderate digestion and dispersion of the

peccant matter. The patient then has a sudden respite, which he falsely

attributes to the last change of position. A gentle perspiration is

succeeded by sleep. He wakes freer from pain and finds the part recently

swollen. Up to this time the only visible swelling has been that of

the veins of the affected joint. Next day (perhaps for the next two or

three days), if the generation of the gouty matter have been abundant,

the part affected is painful, getting worse towards evening and better

towards morning. A few days after the other foot swells, and suffers

the same pains. The pain in the latter regulates the state of the one

first attacked, for the more acutely it is tortured the more perfect

is the abatement of suffering and the return of strength in the other.

Nevertheless, there is a repetition in the second case of all the misery

of the first both as regards intensity and duration. Sometimes during the

first days of the disease the peccant matter is so exuberant that one

foot is insufficient for its discharge. It then attacks both, and that

with equal violence. Generally, however, it takes the feet in succession.

After it has attacked each foot the fits become irregular both as to the

time of their coming and as to their duration. One thing, however, is

constant—the pain increases at night and abates in the morning. Now a

series of lesser fits like these constitute a true attack of gout, long

or short, according to the age of the patient. To suppose that an attack

two or three months in length is all one fit is erroneous. It is rather

a series of minor fits. Of these the latter are milder and more limited

in their extent than the former, so that the peccant matter is discharged

by degrees, and recovery follows. In strong constitutions, when the

previous attacks have been few, a fortnight is the length of an attack.

With age and impaired habits gout may last two months. With _very_

advanced age, and in constitutions _very_ much broken down by previous

gout, the disease will hang on till the summer is far advanced. For the

first fourteen days the urine is high-coloured, has a red sediment,

and is loaded with gravel. Its amount is less than a third of what the

patient drinks. During the same period the bowels are confined. Want of

appetite, general chills towards evening, heaviness, and a troublesome

feeling even in the parts which are free from the attack, attend the fit

throughout. As it goes off the foot itches intolerably, mostly between

the toes; the cuticle scales off, and the feet desquamate, as if venomed.

The disease being disposed of, the vigour and appetite of the patient

return, and this in proportion to the violence of the last fits. In the

same proportion the next fit either comes on or keeps off. Where one

attack has been sharp, the next will take place that time next year, not

earlier.”—_Sydenham._

[32] “Pain is better borne by the poor man, as I have had opportunities

of seeing, than by the man who acquired or promoted his gout with two or

three bottles of port wine daily, with the surroundings which such luxury

implies.”—_Longstreth_, “_On Gout_.”

[33] “The pain is altogether disproportionate to the other signs of

inflammation, and, even more, to the consequent structural changes in the

inflamed part.”—_Paget._

As to the peculiar character of the pain, Duckworth states: “Nothing at

all like it occurs in any other joint disease.”

[34] Sydenham noted that “sometimes the morbific matter is thrown upon

the elbows and occasions a whitish swelling, almost as large as an egg,

which becomes gradually inflamed and red.”

[35] “_Regular gout_ may _supervene suddenly, and be chronic_; that is

to say, its outbreak need not have been preceded by paroxysms in any way

characteristic of acute gout.”—_Trousseau_, “_On Gout_.”

[36] As Trousseau puts it: “Regular chronic gout, in respect of the

frequency of the recurrence of the paroxysms, resembles acute gout with

successive paroxysms, there being this capital difference, however, that

its attacks are longer and during the intervals are not entirely absent.”

[37] Mr. James Moore, surgeon to the Second Regiment of Life Guards

(_Medico-Chirurgical Transactions_, 1809, Vol. I.):—

“This effusion” (meaning the milky fluid containing the urate of soda)

“occurs not only during fits of gout, but likewise in the intervals; and

as the extremities, particularly the hands and feet, are the principal

seat of gout, it is there the greatest accumulation of chalk takes place.

Though this process is usually preceded and accompanied by inflammation,

the chalk is never inclosed in a cyst, like pus in an abscess. It lies

usually in the cellular membrane, in the bursæ mucosæ, or in the cavities

of the joints. I have even seen it thrown out between the cutis and the

cuticle. But, as the gouty inflammation is of the erythematous kind,

there is no extravasation of coagulable lymph, and no new-formed covering

surrounding the chalk. This point is of the first importance, and

explains many of the peculiarities of gout, which is generally considered

as a phlegmon. But the absence of coagulable lymph in the inflamed parts

I consider as full evidence of the inflammation being erythematous.

“The chalky liquid when first secreted gives to the finger the feeling

of fluctuation, and cannot be distinguished from the ordinary serous

effusion of gout. But unfortunately the absorbents cannot suck up the

chalky particles. The consistence of the liquid therefore becomes thicker

and thicker, till at last nothing remains but a hard mass. When even a

considerable effusion of this kind occurs, the quantity of chalk which

ultimately remains is comparatively small, as by far the greater quantity

is merely serum. It therefore usually requires repeated effusions to

form any great mass of chalk, and the consistency depends upon its age

and the activity of the absorbents. The quantity at last accumulated by

repeated paroxysms is in some instances immense, which augments very

seriously the sufferings of the gouty. The distress, however, is not

owing to any irritating quality in the chalk, but to its obstructing the

motion of the tendons and joints, occasioning often complete anchylosis,

and pressing and distending the surrounding parts by its bulk. It acts,

therefore, by mechanically embarrassing the machine of the body, and not

upon the living principle, for it will often remain for years in parts

highly sensible without exciting the slightest pain or inflammation.

Although these concretions are of so mild a nature, they often are the

cause of extensive mischief, bursting externally, occasioning ulcers

very difficult to heal. When a violent fit of the gout attacks a chalky

tumour, the appearance is frequently very alarming, the new paroxysm

being accompanied with a fresh serous and chalky effusion, which, added

to the old deposit of chalk, occasions a prodigious swelling; the cutis

when distended to the utmost opens, yet sometimes the cuticle remains

entire. The chalky or serous liquid may then be seen through the

semi-transparent epidermis. The surrounding integuments appear of a deep

red, or of a purple hue, threatening mortification, while the pain is

excruciating.

“At length the cuticle gives way, a discharge of serum and chalk takes

place, and a remission of all the symptoms usually follows. During the

whole of this alarming process suppuration never occurs; but soon after

the opening has taken place suppuration commences, and pus and chalk are

then discharged from the ulcer. There are several unexpected occurrences

in the progress of such ulcerations. When an opening is formed, the

whole of the chalk never escapes, and its complete evacuation is often

a very tedious process; this is owing to its being diffused through the

cellular membrane, as in the cells of a sponge. One cell must sometimes

give way after another, and small portions of chalk are successively

thrown out, so that months and even years pass away before the whole

is discharged. It also frequently happens that the orifice contracts

and closes over, leaving portions of chalk underneath. This kind of

cicatrix sometimes stands its ground, but more commonly breaks out again

and again to discharge chalk. Even openings into joints, which are so

dangerous when occasioned by other extraneous bodies, are often attended

with no serious symptoms when the joint is filled with chalk. On such

an accident happening a surgeon unacquainted with these peculiarities

might be tempted to propose large openings, or even amputation, as the

only resource for hindering extensive inflammation and carious bones. But

if he treats the disease mildly, he will find that no such severe plans

are requisite, for the parts will probably fall into a very tranquil or

indolent state; a sore will continue for a certain period, discharging

pus, and occasionally a bit of chalk, till at last the orifice will

close up. Independent of the opening formed by a fit of the gout, the

skin, stretched over a mass of chalk, is sometimes thinned, absorbed,

and pierced by mere pressure. At other times this is effected by common

inflammation and suppuration. When openings take place in these milder

ways, a less quantity of chalk is usually evacuated; but this depends

entirely upon the degree of inflammation. When the suppuration is great,

it naturally detaches and washes out a greater quantity of chalk.

“The last peculiarity is the rarest, namely, that a dry, hard piece of

chalk shall pierce the skin, and remain like an excrescence, without

exciting either inflammation or suppuration.”

[38] According to Adler, about one-tenth as much uric acid is excreted in

the sweat as in the urine, sweat containing 0·1 mg. per cubic centimetre.

[39] In this connection the tendency of gouty glycosurics to exhibit

boils and sometimes carbuncles should not be forgotten.

[40] Max Strunsky, of New York, discussing the frequency with which

by the older physicians gouty forms of arthritis were confused with

gonorrhœal, syphilitic, and other undifferentiated forms of infective

arthritis, makes the following observation: “Also flatfeet must have

added herds of cases, for this pathological entity was as yet unknown.

The rich man in pursuit of his pleasure and the poor man from prolonged

standing at his labour strained their arches then as they do now, and

women by their ultra-fashionable shoes, which fashion decreed upon

them in certain periods of history, produced painful feet which were

undoubtedly mistaken for gout. That patients with local foot trouble were

treated for gout the writer can speak from experience. A typical case

is of a woman who came to his office two years ago. She had broken-down

anterior arches. Hallux valgus, hammer-toes, and bunions were present,

and the heels were small and undeveloped. Her feet were one mass of pain,

and they looked infantile, reminding one of a Chinese woman. All her

adult life she wore high-heeled, narrow, pointed, tight shoes. She said

that for twenty years she had been treated for gout.”

[41] In support of this contention, I would note that Charcot, while

he gives us an inimitable account of the _tophaceous_ variety of gout,

introduces also another variant, as he deems it, of _chronic articular

gout_. The joint changes in this latter are marked by what he terms

“a thorough atrophy,” including the superjacent skin, which “is pale,

shining and polished.” With this are associated ankyloses, angular

deflections, and partial dislocations. The joints, he states, “may be

absolutely free from swelling, for example when the extra-articular urate

deposits _either do not exist at all, or only mere traces of them, or

when only the articular cartilages are invaded by the urate of soda_.”

It cannot, we think, be doubted that the clinical content of this group

is largely made up of _rheumatoid_ or _atrophic arthritis_. The evidence

that these examples, _quâ_ _uratic deposits_, are of “gouty” nature, is

obviously very slender.

Reverting to Sir Dyce Duckworth, this authority also recognises two

varieties of chronic articular gout: (_a_) tophaceous gout; (_b_) chronic

deforming gout, with as its synonym _arthritis deformans uratica_. As

to the clinical content of this latter group he writes: “The fingers,

hands, and wrists show various deformities depending on _over-growth_ of

_articulating ends of bone_, _cartilage_, ligaments, and bursæ. _These

may be complicated with visible or invisible tophaceous deposits_.” As to

these anatomical alterations, Duckworth regards them as “similar to, but

not the same as, those induced by rheumatic disease.” But he adds: “It is

very rare for the deformities of true gout to attain the gross characters

peculiar to chronic rheumatic arthritis; they are altogether of lesser

degree in the majority of the worst instances.” From a careful study of

their anatomical characters, I cannot avoid the conclusion that they were

in the main examples of the hypertrophic variety of arthritis deformans,

viz., _osteoarthritis_.

[42] As Sir W. Hale White has pointed out, “pads” not uncommonly develop

on the dorsal aspects of the mid-phalangeal joints. They range in size

from a split pea to a hazel nut. Histologically they are the outcome of

an excessive overgrowth of fibrous tissue beneath the corium. They in

no way involve the joints, but, according to Hale White, they have been

confused with osteoarthritis. Their frequent association with Dupuytren’s

contracture might conceivably lead to their confusion with gout also,

inasmuch as that deformity is so widely attributed to a “gouty” habit.

[43] Sir Spencer Wells in his “Practical Observations on Gout and its

Complications and on the Treatment of Joints stiffened by Gouty Deposits.”

“Of the many cases related by authors as anonymous disease by far the

greater portion were connected with a gouty diathesis, as indicated both

by the formation of calculi, by the occurrence of regular paroxysms

of gout, and by the descent of the individual from gouty ancestors;

they are cases, in fact, which would have been better understood and

better treated if they had been termed ‘anomalous gout’; but as the

subjects are young females, they are of course set down as ‘anomalous

hysteria.’”—_Laycock_: “_Nervous Diseases of Women_.”

[44] “Diseases of the Eye” (1918), p. 258.

[45] “Diseases of the Eye” (1919).

[46] “Diseases and Injuries of the Eye” (1913).

[47] Kruckmann, _Med. Klinik._, 1910, No. 38.

[48] _Proc. Roy. Soc. Med._, Ophth. Section, 1914, p. 66.

[49] _Ophth. Hosp. Reps._, VII., p. 287, 1873.

[50] “Diseases of the Eye” (1854), p. 558.

[51] _Brit. Med. Journ._, 1885, R. Clement Lucas.

[52] _Lancet_, 1920, Vol. I., p. 500, Browning.

[53] _Archives d’Ophtalmologie_, Vol. XII., p. 623.

[54] A very rare form of iritis was described by the late Mr. Doyne as

guttate iritis (_Trans. Ophth. Soc._, Vol. XXX., p. 91) because the

appearances resembled drops of lymph on the margin of the pupil. In his

view it was a true form of gouty iritis, but the diagnosis does not seem

to have been confirmed by other observers. Even if we grant that his

view is possibly correct, we must beware how we generalise on a basis of

exceptions and freaks.

[55] _Brit. Med. Journ._, 1903, Vol. II., p. 138.

[56] “Gout” (1876), p. 450.

[57] _Clin. Soc. Trans._, Vol. XI., p. 132, 1898.

[58] “Medical Ophthalmoscopy,” 3rd edition, p. 267.

[59] _Practitioner_, 1909, Vol. II., p. 61.

[60] Sydenham, discussing a milk diet, observes that “it has done good

as long as it has been rigidly attended to. The moment, however, that

the patient swerves from it a hair’s breadth, and the moment he betakes

himself to the diet of a healthy man (no matter how mild and simple), the

gout returns worse than ever.”

[61] “The lighter beers of Germany, Austria, and Scandinavia, appear to

be harmless for the gouty unless taken immoderately. Residents in towns

goutily disposed, leading sedentary lives, are seldom long tolerant even

of light laager beer.”

[62] Sir Archibald Garrod has suggested that guaiacum has a distinct

effect in reducing the amount of uric acid excreted, _i.e._, it

was thought that the uric acid is eliminated in some other form,

possibly hippuric acid. Accordingly Martindale and Westcott conducted

investigations to determine whether this resin increases or decreases the

elimination of uric acid from the human body.

A normal individual took guaiacum resin in 5-grain doses daily in the

morning, and the uric acid was estimated in the urine the same afternoon.

Hippuric acid was also estimated in specimens of the same urine by the

method given by Allen, “Chemistry of Urine,” p. 186. After a day’s

interval the acids were estimated on several days without administration

of the drug. The two series were then repeated on the same lines after

an interval. Seeing that the diet of the individual could not well be

controlled in weighed amounts of food, as would strictly be necessary for

an investigation of this kind, it was thought that to express the results

in percentage ratios of uric acid to excess of solids (R.U.A.) over water

might yield more comparable results.

Joulie employs this method of indicating the constituents of urine by

ratios; _cf._ Vol. I., p. 736. Thus, taking a specimen of urine with the

following “normal” factors in grams per litre:—

Specific gravity 1017·8

Excess of solids over water 17·8

Physiological acidity in terms of H₂SO₄ 0·849

Total P₂O₄ 2·083

Cl 6·865

Urea 18·75

Uric acid 0·416

Hippuric acid 1·3

(_mean_).

One may express the constituents as the following percentage ratios:—

Normal.

“R.A.”—Ratio of physiological acidity to excess

of solids over water 4·77 0·849 × 100

-----------

17·8

“R.P.”—Ratio of total P₂O₄ to excess of solids over

water 11·17

“R.U.”—Ratio of urea to excess of solids over water 100·53

“R.U.A.”—Ratio of uric acid to excess of solids over

water 2·33

“R.H.A.”—Ratio of hippuric acid to excess of solids

over water 7·3

“R.P./R.A.”—Ratio of phosphoric acid to ratio of acidity

(Joulie’s factor, _cf._ Vol. I., p. 737) 2·45

Ratio of uric acid, for example, is arrived at thus 0·416 × 100

----------- = 2·33

17·8

The results which we obtained are given in the following table:—

_Effects of Guaiacum Resin on the Urine of a Normal Individual._

-----------------+---------+-------+-----+------+------+--------+--------

| Date. | Sp. |Urea.| Uric | Hip- |“R.U.A.”|“R.H.A.”

| | Gr. | | Acid.| puric| |

| | | | | Acid.| |

-----------------+---------+-------+-----+------+------+--------+--------

With guaiacum | 28/12/11| 1·0107| 2·29| 0·09 | 0·09 | 4·43 | 4·34

With guaiacum | 29/12/11| 1·0247| 1·29| 0·08 | 0·1 | 3·34 | 4·04

With guaiacum | 1/1/12| 1·0215| 2·56| 0·015| 0·15 | 4·88 | 6·97

With guaiacum | 2/1/12| 1·0141| 2·82| 0·10 | 0·2 | 4·2 | 8·20

Without guaiacum | 4/1/12| 1·0229| 2·42| 0·06 | 0·1 | 2·62 | 4·36

Without guaiacum | 5/1/12| 1·0249| 2·42| 0·08 | 0·2 | 3·16 | 8·03

Without guaiacum | 8/1/12| 1·0255| 3·09| 0·10 | 0·225| 4·11 | 8·12

With guaiacum | 11/1/12| 1·0233| 2·56| 0·09 | 0·1 | 3·7 | 4·29

With guaiacum | 12/1/12| 1·0213| 1·88| 0·075| 0·1 | 3·05 | 4·69

Without guaiacum | 24/1/12| 1·0239| 2·42| 0·08 | 0·038| 3·45 | 1·57

Without guaiacum | 25/1/12| 1·0229| 2·15| 0·06 | 0·05 | 2·61 | 2·18

-----------------+---------+-------+-----+------+------+--------+-------

Average uric acid ratio under guaiacum resin = 3·39

Average uric acid ratio without guaiacum resin = 3·19

Average hippuric acid ratio under guaiacum resin = 5·43

Average hippuric acid ratio without guaiacum resin = 4·49

The quantity of hippuric acid normally found is known to vary enormously,

_e.g._, between 0·02 and 0·25 per cent. From this we deduced, for

purpose of this investigation, a mean normal R.H.A. of 7·3. A number of

other investigations were conducted on analogous lines, but need not be

recorded.

From the results of these experiments one notices an average increase

of uric and hippuric acids during the “+ guaiacum” periods. It is not

possible to draw a conclusion without further corroboration. The amount

of each acid from day to day is seen to be erratic, and the process of

estimation of hippuric acid is not accurate.

[63] “Weakly mineralised thermal muriated waters, such as those of

Baden-Baden in Germany, and Bourbon-Lancy in France, which in character

and action approach the simple thermal group, may also show great

radio-activity. In fact, the Büttquelle of Baden-Baden in this respect

rivals some of the most radio-active springs of Gastein. Of Bourbon-Lancy

springs, according to A. Piatot, the least mineralised are the most

radio-active.”—“_Climato-therapy and Balneo-therapy_,” _by Sir Hermann

Weber_.

[64] SIR WILLIAM RAMSAY’S ANALYSIS OF THE BATH WATERS.

Density of the water from King’s Well 1·0166

Osmotic pressure equivalent to that of

a salt solution containing per litre 1·09 grams NaCl.

Volume of gas in twenty-four hours from—

Litres.

King’s Well 4,927

Cross Spring 218

Hetling Spring 218 (estimated).

-----

5,363

-----

Analysis of gas (King’s Well)—

Parts per 10,000.

Carbon dioxide 360

Nitrogen, etc. 9,640

No oxygen, no hydrogen, no marsh gas.

The nitrogen contains—

Argon 73·63

Neon 23·34

Helium 2·97

From all three wells in twenty-four hours—

Litres.

Argon 39

Neon 12½

Helium 1½

_Gases dissolved in Pump-room Water._—This water contains 18·5 volumes

of gas per 1,000 of water. Its composition is—

Carbon dioxide 6·9

Nitrogen 11·6

It had become somewhat aerated on drawing, but allowance has been made

for that.

Milligrams per

million litres.

Radium in the water of the King’s Well 0·1387

Niton (radium emanation) in the water of King’s Well 1·73

” ” ” ” of Cross Bath 1·19

” ” ” ” of Hetling Bath 1·70

” ” ” in the gas from King’s Well 33·65

[65] Bickel in a series of experiments in which the acid contents as

well as the total amount of gastric juice were considered obtained the

following results: simple gaseous waters (Apollinaris, Giesshübl),

muriated waters (Rakoczy spring of Kissingen, Wiesbaden, Kochbrunnen),

and muriated alkaline waters (Ems, Selters), all of them, as compared to

distilled water and ordinary tap water, rather increased than decreased

the specific secretory activity of the gastric mucous membrane, whereas

simple alkaline waters (Vichy) and sulphated alkaline waters (Karlsbad)

had a slight tendency to diminish, and the sulphated “bitter” waters

(Hunyadi Janos water) decidedly diminished, the gastric secretory

activity, although “bitter” waters sometimes induced a watery flow from

the gastric mucosa, which increased the fluid contents of the stomach.

[66] Bain, of Harrogate, from his observations on a man with permanent

cutaneous biliary fistula, found that the old sulphur spring of Harrogate

increased both the quantity of bile and the bile solids. This, he thinks,

may “fairly be taken as an index of the degree to which it stimulates the

liver, and is, in fact, the most reliable indication of the value of a

cholagogue.”

INDEX

=A-amino-acids=, 61