General Hydro-therapy
That hydro-therapy constitutes one of the most effective, if not the most effective, methods of treating gout, is almost a truism, if judged by that most “acid test”—Experience. The particular applications we are about to discuss entail exposure of the whole body. In other words, those measures directed more especially to treatment of the underlying causal state—the correction of that warp of metabolism or auto-toxic state of which the arthritic, muscular, or other lesions are but local manifestations.
It goes without saying that, with this for our objective, there is much need for discrimination in the selection of measures suitable for individual cases, and, naturally, the basis of such differential treatment is thorough physical examination prior to embarking on the course. Yet how frequently on their own initiative do these subjects enter lightly upon a series of baths, mingling stimulant and sedative procedures in haphazard fashion, unwitting that hydriatric measures are capable of infinite harm when misapplied.
For in hydro-therapy the personal equation is of prime importance, varying with individual reactive peculiarities. In short, the character of the response differs widely in different subjects, efficiency or not of the nervous and circulatory functions being the chief controlling factors. Hence accurate appraisement of the reactive powers of the constitution to hot and cold applications is the basis of rational hydro-therapy.
Thus nervous irritability is the outstanding characteristic of some gouty constitutions. They are therefore intolerant of extremes of temperature, and for them sedative or sub-thermal baths are the most suitable.
Others suffer from torpid circulation and sluggish vascular response, and in their instance, stimulant measures, hot or cold, in sequence or in alternation, are indicated. Again, some are obese, and others lean, and while of the twain the former react more feebly, on the other hand, they stand prolonged courses of hydro-therapy more satisfactorily. In contrast, the thin, though they react well, are more readily exhausted, and so apt to suffer from “secondary chill” or other untoward consequences.
Prophylactic Measures.—As we have noted, the “gouty,” more than others, are intolerant of atmospheric vicissitudes. Accordingly, if we would strengthen their defensive mechanisms in this respect, we must endeavour to train them to react more adequately to cold or sub-thermal impressions.
Of the value of thermal applications in chronic gout I am convinced, but, on the other hand, we must not blind ourselves to the value—prophylactically speaking—of their judicious conjunction with sub-thermal or cold procedures. For these latter stimulate oxidation processes, and in chronic gout, according to many, there is deficient oxidation of protein waste, while, apart from this, in the gouty obese there is imperfect oxidation of adipose tissue.
Prophylactic measures to be of any real avail must be continuous, and spas or hydropathic establishments should indeed be more alive to their educational responsibilities in this matter, for the benefits of hydro-therapy as regards prophylaxis are within the reach of all possessed of the convenience of a modern bath-room.
They should be taught to inure themselves by taking daily a tepid bath followed by a cold shower or rain spray. If this be too drastic, let them, while standing in warm or tepid water, briskly rub the rest of the body with a coarse towel wrung out of cold water, into which, if liked, salt has been added to the point of saturation. In this way the tonic effects upon the skin of hypo-thermal or cold applications may be invoked, and thereby its undue sensitiveness is reduced and therewith the liability to subsequent attacks.
It now devolves upon us to consider under what circumstances hydro-therapy is inadvisable, and, incidentally, those ill-effects that indicate its modification or abandonment.
Contra-indications and Untoward Complications.—Authorities generally seem unanimous on this point, viz., that the chief sphere of hydro-therapy is in chronic or subacute gout. On the other hand, they are equally unanimous in proscribing its exhibition in acute forms of the malady. Speaking for myself of the Bath waters, I am quite convinced that the distinguished physician, Caleb Hillier Parry’s pronouncement, “that the Bath waters, in no form whatever, are beneficial during the paroxysms of gout, or in any inflammatory disposition which may exist in the interval,” is not only true but capable of extension to all forms of hydro-therapy as applied at this stage of the disorder.
Nor do I think it advisable if prodromal symptoms suggestive of the imminence of an attack are present. It is too, I think, impolitic—after the subsidence of a severe attack—to resort too quickly thereto, the more especially if there is a disposition to what our forefathers termed “flying gout.” In either event, an acute outbreak is most likely to ensue, and, though there is doubtless some truth in the old idea that a gouty subject feels better after an attack, still it is not, I think, the physician’s rôle to evoke gout, but rather to prevent its explosion. Occasionally mischances of this sort will happen, but only exceptionally, if the foregoing safeguards be respected. Certainly if the patient seems palpably on the verge of an attack it is but discreet to postpone baths until the good effects of free purgation and strict dieting have been derived.
Indeed, I would go further, in that I think that, under all circumstances, a course of hydro-therapy should be preceded by free evacuation of the bowels. We should then hear less of that disturbance of the system known as “well-fever” or “poussée-thermale,” which, it is not sufficiently recognised, may follow not only internal but external use of mineral waters. I allude to dyspepsia, lassitude, or skin eruptions, etc., symptoms which formerly were thought to be of critical or beneficial nature, but which, I agree with Dresch, are probably the result of an auto-intoxication, and, as he thinks, more or less combined with an infection by the bacillus coli. Should such symptoms supervene during a course, the baths had better be omitted for two or three days pending their disappearance under appropriate measures.
In the same way, there are reservations regarding the suitability of baths in chronic gout. Thus, if complicated by advanced cardiac or renal disease, hydro-therapy is often contra-indicated, and, in any instance under such circumstances, has to be undertaken very cautiously. On the other hand, it is wonderful how well many examples respond if due discrimination be exercised. Especially suitable are those cases of gout and renal disease in which the heart is hampered by increased peripheral resistance. Such cases under Aix massage, frequently, as Bain and Edgecombe pointed out, improve strikingly through the consequent reduction of arterial pressure.
Turning now to the untoward results or complications of hydro-therapy, hot baths, if of too high a temperature or too prolonged, may cause vertigo, fainting, or palpitation—an indication for reduction in temperature and duration. Or, if douches are used, the pressure may be excessive. Insomnia, again, may follow over-stimulation, and our measures must be altered accordingly. Loss of appetite and strength, too, may be the outcome of too drastic treatment and excessive reaction.
It is well, also, that during a course of hydro-therapy the patient’s body weight be taken from time to time, and note made whether he is gaining or losing in muscular strength. If weight sink and, coincidently, strength increase, all is well with the gouty obese; but if muscular capacity be waning, excessive demands are being made on the subject’s oxidising and eliminative processes.
Examination of the urine, too, may yield indications of value. A notable increase in the output of chlorides suggests excessive tissue waste, and of phosphates too marked excitation of the nerve centres, and the appearance of albumen or sugar, if previously absent, will indicate reduction in intensity of the hydriatric procedures. In short, we should be alive to the profound influence of hydro-therapy on general metabolism and the consequent necessity of medical supervision throughout the course.