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.