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.