Gout, with a section on ocular disease in the gouty

by Llewellyn J. Llewellyn

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.