Gout, with a section on ocular disease in the gouty

by Llewellyn J. Llewellyn

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.”