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.