Chapter XXXII: Mineral Springs and Choice of Spa (1)

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.