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.
Methods of Application of General Hydro-therapy
Subject to reservations, stimulant hydro-therapeutic procedures are in chronic gout the special indication. Thermal waters, therefore, are, generally speaking, the most suitable, and cæteris paribus, the higher the temperature the greater the excitant action. Of natural thermal baths, those of Bath, Aix-les-Bains, Gastein, Wiesbaden, etc., enjoy great repute, and, judging from personal experience of the first-named spa, I doubt not that—given due discrimination—all waters of this group are unquestionably beneficial.