Sir Alfred Baring Garrod.

A treatise on gout and rheumatic gout (rheumatoid arthritis.) online

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of the acidity of the urine from the use of the bath, even
when free nitric acid is contained in it. From these
observations Dr. Parkes is inclined to think that writers
in general have been too ready to assume the permea-
bility of the human skin by different saline substances.
I have, however, found distinct evidence of iodine in the
urine after the use of a lotion containing the compound
tincture of that substance, and have also seen symptoms
of iodism produced by the external use of iodine paint.
The whole subject deserves much further investigation.

Various mucous membranes, especially that of the
bladder, are also influenced, and the mucus from them
becomes less tenacious, and often diminished in quantity.
The perspiration has likewise been supposed to undergo
a change in reaction ; the bowels are seldom affected,
unless the waters are improperly administered.

For the first few days of taking the waters few
symptoms are observed, but occasionally patients com-
plain of some weariness of the limbs, weight of the head,
and a feeling not unlike slight hitoxication accompanied
with a desire for sleep ; and sometimes there is also an
increase in the disease for which the treatment has been
adopted. These first symptoms are not considered of
any importance, for, if the medication be continued, they
often disappear and are succeeded by a feeUng of in-
creased vigour.

If, however, the same symptoms return afler the treat-

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ment has been pursued for some time, their significance
is much greater, as they indicate a condition of saturation
of the whole system, and the waters must be at once
taken less freely or discontinued, to be resumed again or
not according to circumstances.

In 1840, the French Academy of Medicine caused a
report to be drawn up by a commission formed to investi-
gate the subject of Vichy waters in the treatment of gout,
and in pursuance of their inquiry, many questions were
asked of the late Dr. Petit, then Mddecin Inspecteur at
Vichy ; we shall perhaps place the subject in a clear and
simple hght by giving a short summary of the report
thus elicited.

Dr. Petit considers that the waters may be employed
when a fit of gout is impending, and even when it has
begun to develop itself, and he thinks that the accom-
panying fever, if simply dependent on the articular affec-
tion and in no way connected with any disease of the
organs of the chest or abdomen, need not be regarded
as a contra-indication. However, there are certain
patients who are very susceptible, and in whom the
tolerance for the waters diminishes or entirely ceases
when an attack of acute gout affects the joints ; in such
cases it is right either greatly to decrease or altogether
to suspend the use of the waters. On the decline of the
fit it is also necessary to act with much pnidence, for
fear of reproducing the attack ; active treatment should
not be recommended too soon, and it is especially neces-
sary to avoid the early use of the bath.

The results obtained from the waters are much more
prompt, more complete, and consequently more striking,
in acute than in chronic forms of gout; in the latter
the intervals are short, and the treatment must be per-
severed in for a long time, in order to give the patient a

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chance of regaining the use of the joints ; and even then
the advantage is by no means certain. During a course
of treatment in chronic cases the disease sometimes
assumes an acute character, but this is not essential to
the success of the cure.

Dr. Petit considers that chalk-stones are occasionally
absorbed, although it is a rare occurrence ; but he thinks
that when patients are submitted to the Vichy treatment,
and this is persevered in for a long time, new concretions
are but rarely formed.

The effect of the treatment is to diminish the violence
of the fit and somewhat abridge its duration, but its chief
object is to combat the proximate cause of the disease
and prevent its return.

Dr. Petit remarks that, as a rule, the Vichy waters
agree well with the gouty, but he advises moderate doses,
as for example five or six glasses each day, together with
the administration of a bath. If this quantity is easily
supported, the number of glasses may be increased to
twelve or even fifteen. Some patients have taken as
many as twenty without inconvenience, imagining that,
if reUef be obtained from small quantities, much more
advantage will accrae from larger, and so the prescribed
amount is often exceeded. Certain individuals have been
known to drink thirty, forty, and fifty glasses ; and it is
stated that one man took as many as eighty-four glasses
in the twenty-four hours.

Dr. Petit considers that the waters of Vichy owe their
efficacy in gout to the fact of their containing a consider-
able amount of soda, and that other waters similarly con-
stituted would have the same value. He also thinks
that, as the waters contain the soda in the form of the
bicarbonate, they are useful when taken at a distance
from their source ; but that, as a rule, they do not sit so

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easily on the stomach and cannot be taken in so large
quantities as at the springs.

During the first and second years of treatment, full
saturation of the patient is considered of advantage, and
for this purpose at least a month's exhibition of the
waters is necessary ; considerable benefit is often obtained
from prolonging the treatment even beyond that time,
especially if stiffening or anchylosis of the joints is

Patients occasionally experience a repugnance for the
waters, accompanied with want of sleep and a feeling of
agitation, and sometimes this is shown at an early period
of their exhibition ; when it occurs the treatment must
be at once discontinued.

Having thus exposed the principal views on the treat-
ment of gout by the use of the Vichy waters which were
held by Dr. Petit, a gentleman who had abundant oppor-
tunities of becoming thoroughly versed in the subject, it
is only right to observe that his opinions are not gene-
rally received even by French physicians : for example,
Dr. Durand Fardel, Inspector of the Sources of Hauterine
near Vichy, who has also written on the subject, differs
considerably from Dr. Petit on several important points ;
for, although he is fully of opinion that much benefit is
often derived from the use of the Vichy waters in gout,
and that, if they do not cure the disease, still they exert
a salutary influence upon the general health as well as
on the symptoms of the malady, he nevertheless considers
that their exhibition demands much caution. Dr. Durand
Fardel believes that Vichy waters do not cure gout by
specially influencing the uric acid, but merely by produc-
ing an alterative effect. As the mineral waters act as
general excitants to the whole organisation, and especi-
ally to the secreting organs, he thhiks they should only

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be employed under certain circumstances, which may be
thus briefly stated.

They should not be taken either when a fit of gout is
threatened or at its commencement, or during its con-
tinuance, or after its decline, until we are fully assured
that it has completely passed off.

The time most favourable for the exhibition of these
waters is during complete freedom from the attacks.

There are several cases on record of gouty subjects
having died suddenly soon after commencing the Vichy
treatment, but these patients were suffering not only
from gout but likewise from organic disease of some im-
portant organ. Sometimes the disorder appears to have
been rendered more chronic, and sufficient evidence of
the occurrence of ill effects has been given to make it
advisable to use great caution, not only in the mode of
the employment of the waters, but likewise in the selec-
tion of the cases.

Having seen cases of gout exhibiting every variety of
phase, in which Vichy waters have been employed, and
having witnessed the plan of treatment adopted at the
baths, I feel entitled to give an opinion upon the subject.
Vichy waters are undoubtedly agents which powerfully
influence the whole economy and alter the character of
the animal fluids, and, if they are sometimes potent for
good, they are also capable of causing much evil.

With regard to their exhibition in gout, I consider
them to be often injurious in chronic cases, especially
when the system is already lowered, and the rapid forma-
tion of urate deposits is taking place either in the joints
or upon the surface of the body ; I believe that they
sometimes increase these deposits and still further de-
press the vital powers. I also think that the constitution
of Vichy waters is not such as to render them desirable

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in all gouty cases, inasmuch as an excess of carbonate of
soda rather tends to diminish than augment the solubility
of urate of soda, which is always present in the blood in
these subjects. In many forms of chronic gout the baths
are useful, but then their value is independent of any
peculiarity in their composition.

In acute gout, Vichy water, taken in moderate quan-
tities, either during the attack, or when a fit is impend-
ing, or in its decline, is not likely to do harm, but the
use of the bath is very hazardous and should never be
risked ; I am confident that, when acute inflammation is
present, other treatment is more appropriate.

In the complete intervals of acute gout, and more
especially in strong and robust subjects, when the disease
depends rather on increased formation than defective
elimination of uric acid, and likewise in cases in which
the liver and digestive functions are considerably at
fault, the employment of these waters is likely to prove
most beneficial ; in other forms of gout mineral waters of
a different class may be resorted to with greater advan-
tage than those of Vichy.

Mineral springs of Wiesbaden (Nassau). The physical
and chemical characters of the Wiesbaden waters may
be represented by those of the Kochbrunnen spring,
which is the one almost exclusively employed. The
water of this spring possesses the following properties.
The temperature is about 160^ Fahr., and it emits
copious vapours ; in odour it somewhat resembles quick
lime, and the taste is not unlike weak but highly salted
chicken broth ; its density is 1006'6, and it contains in
the 1000 parts, 8 parts of sohd matter, and 0*5 parts of
gas. The detail of the analysis by M. Fresenius will be
seen in the Appendix.

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When the water is allowed to remain in contact with
the air, as occurs in the baths, a pellicle forms on the
surface, of a somewhat greasy appearance, but, in reality,
it consists of carbonate of lime, which the escape of
carbonic acid has rendered insoluble, and no appreciable
amount of organic matter is present in it.

It will be evident from the consideration of the nature
of Wiesbaden water, that the eflfects produced by it
upon the economy are due, in part to the exhibition of
water at a high temperature, in part to the saUne matters
contained in it, and more especially to the chloride of
sodium. The lime salts, as the carbonate and sulphate,
probably possess some influence, as also the free car-
bonic acid and the small amount of iron, but these, as
well as the remaining ingredients, play a very second-
ary part compared with that exerted by the common

The physiological eflfects usually produced by these
waters when taken in small doses are, some increase of
the saliva and buccal mucus, giving rise to frequent
deglutition and acuteness of the taste; a feeling of
warmth in the epigastrium, accompanied with eructation
of carbonic acid gas ; along with these symptoms there is
usually an increase of appetite, and improvement in the
digestive functions. After the absorption of the water
into the system, the most appreciable effect is an aug-
mentation of the urinary secretion ; the bowels are
usually not affected by the water unless it be taken cold,
when it sometimes produces a slight aperient action ; on
the other hand, if the patient drinks it very hot, constipa-
tiotx may be induced.

If the water be administered in larger doses, all the
above symptoms become more marked, and unless the
skin and kidneys act very freely, slight diaiThoea is apt

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to occur, with stools rich in the biliary constituents and
other secretions from the intestinal tube. *

These large doses if continued for several weeks,
generally give rise to a diminution in the weight of the
body, and this is more especially seen in the decrease of
abdominal fulness ; cutaneous eruptions, especially acne,
are often developed, and should the waters be persevered
in beyond this point, symptoms indicating the saturation
of the system with the saline matter appear, indicated by
great aversion to the waters, eructations, thirst,' furred
tongue, and a feeling of prostration, pointing out the
propriety of discontinuing the treatment ; if still per-
severed in, vomiting and diarrhoea, congestion of the
organs of the chest and head, and other very unpleasant
consequences may arise.

Dr. Braun, in his work entitled "Monographie des
Eaux Min^rales de Wiesbaden," has given the results of
some experiments made for the purpose of ascertaining
the effects of these waters on the urine, and these appear
to show that a large increase in the elimination of uric
acid and urea arises from their exhibition either in the
form of bath or when taken internally. If these results,
which will be found in the Appendix, were confirmed by
further observation, they would indeed go far to explain
the value of the thermal treatment pursued at Wies-

The action of the Wiesbaden waters in the form of
baths has been investigated by Neubauer and Dr. Genth.
Neubauer found that upon himself half an hour's bath in-
creased the amount of water, also the urea and uric acid,
and, in a slighter degree, the other urinary constituents;
it also increased the free acidity of the urine; but, in
Dr. Genth's case, the effect was different, as the bathing
diminished the urea, and only increased to a very slight

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degree the uric acid. Neubauer found that drinking the
waters increased the urea; Dr. Genth, on the other
hand, noticed a decrease both in the urea and uric acid.
It must therefore be considered that at present nothing
very definite has been made out concerning the physio-
logical effects of the Wiesbaden waters.

The Wiesbaden waters have been strongly recom-
mended in gout, and there are certain forms of the
disease in which they may be advantageously adminis-
tered ; they are more especially indicated for subjects in
whom the circulation is sluggish and the secretions
deficient, also in cases in which there is much stiffness of
the joints from previous attacks. It is not uncommon
for an acute attack of the disorder to supervene after the
waters have been taken for a short time, and when this
happens they must be discontinued. When there is
much debihty, the Wiesbaden treatment should not be
attempted, and great care is necessary with regard to
the use of the baths if there be any symptoms indicating
•disease of the organs of the chest, or much injury of
the kidneys. I have had the opportunity of watching
the effects , of the Wiesbaden waters upon numerous
gouty subjects, but cannot say that they have often been
productive of any great amount of benefit, as they have
not appeared to diminish the frequency of the attacks
or to cause them to become less severe; it must in
fairness be added, that patients seldom resort to Wies-
baden from this country till their gout has become
•chronic and very intractable.

If tlie waters possess the properties ascribed to them
by Dr. Braun, they certainly should not bring on an
acut€ accession, for the blood would be at once rendered
too pure for the occurrence of the gouty fit to be possible.
I believe the waters are more adapted to the treatment

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of chronic forms of rheumatism ; at the same time I have
little doubt that their proper exhibition in many cases of
true gout may be attended with much advantage.

Dr. Robertson informed me that, after seven years'
experience at Wiesbaden, he had come to the conclusion
that the Wiesbaden waters have no very specific action
in true gout, but are more advantageous in chronic forms
of rheumatism ; in gout they are useful if it be desirable
to bring on an attack, which they often do. Dr. Robert-
son also remarked that, when baths were taken, the
patients became much more quickly influenced if the
temperature was under that of the body, but that most
patients took them too warm.

Mineral springs of Baden-Baden. — I have had no
experience of the value of these waters in the treatment
of gout, but as their powers in modifying this malady
have been recently tested by Dr. Ruef, and as lithia has
been found to be an important element in their composi-
tion, I will introduce in this place a portion of a short
article by Dr. Althaus.

'' A very large quantity of lithia was found in two of
the thermal springs of Baden-Baden, namely, the Fett-
quelle and the Murquelle, of which the former contains
0*2315 grains of chloride of lithium in sixteen ounces of
water, and the latter 2 "3649 grains of it. In one
hundred pounds of the salt extracted from the Murquelle,
nine and three-quarter pounds of lithia are contained ;
that is, a quantity of this substance worth 90Z. sterling.
This amount is not equalled by that contained in any-
other mineral spring which has yet been examined.

" In consequence of the analysis of these springs
made by Professor Bunsen, they have, during the last
season, for the first time been extensively used in cases

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of gout and litliiasis ; and I am indebted to my friend
Dr. Ruef, of Baden-Baden, who has treated a large
number of cases of that description with them, for the
following particulars regarding the result of their ad-

"The physiological effects observed after taking the
waters are as follows : — At first it promotes digestion,
and a feeling of well-being is induced ; but after they
have been taken for some time, and especially in large
doses, sickness, disposition to vomiting, and diarrhoea
ensue, which in most cases, however, gradually dis-
appear, but sometimes continue as long as the water is
drunk. A constant effect is an increased elimination of
urine, the quantity of which is often doubled, or even
trebled; it becomes turbid after some time, and large
quantities of a reddish sediment are deposited in it. In
some of the patients treated by Dr. Ruef profuse per-
spiration came on after from five to ten days, and con-
tinued as long as the water was drunk ; and hi the case
of a lady who had not freely perspired for years this
perspiration even continued two months after the cure
had been finished. It therefore appears that the water
is a diaphoretic as well as a diuretic.

"Concerning its therapeutic action; in almost all cases
the pain in the joints is increased at first (especially in
those patients who were in the end cured) to a rather
high degree, but it never spread to healthy parts. In
joints which were perfectly contracted, crackling, drag-
ging, and pulling were felt, as if the articulations were
being torn asunder ; but after such an attack of pain a
sensation of easiness and decided improvement was felt,
and the mobility of the limb was much increased. In
one patient, a physician from Epemay, a regular fit of
gout came on during the use of the water, under the

E E 2

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continued use of which this patient so rapidly improved,
that he could walk about again after three days.

" Gouty affections of the joints, of the sheaths of the
nerves and the muscles, if not of very long standing,
were cured after three or four weeks, and have remained
so up to the present moment. In periodically recurring
headache on one side, which is often due to gout, the
effects were also very beneficial. A lady who had been con-
tracted for fourteen years, and who could neither stand,
nor walk, nor carry a spoon to the mouth, was by the
use of this water so much improved that she was able to
walk a little, and to stand and eat by herself, while no
former medication had relieved her. This patient also
suffered from dysmenorrhoea, the most prominent symp-
toms of which were severe abdominal pain, oppression
and asthma, cold and paralysis of the left arm. She had
only taken the lithia water for eight days when the
catamenia appeared, and were unaccompanied by any
unpleasant symptoms whatever ; nor did these latter
reappear afterwards. In a male patient whose finger-
joints were infiltrated with urate of soda, which was
visible in white specks through the skin, these infiltra-
tions were removed, and the swelling diminished.

"The mode of administering the water was as follows: —
For patients with whom large quantities of water do not
agree, five grains of the carbonate of lithia were added
to a bottle of the water of Murquelle, which contains
five grains of chloride of lithia ; and the water was then
impregnated with carbonic acid, in order to render the
carbonate more soluble. Of this water a tumblerful was
drunk three times a day ; and if an increase of the dose
appeared necessary, two or three grains of the carbonate
were added to every glass. If patients are able to keep
much water on their stomach, they may take six or

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eight tmnblersful of the Murquelle, without any artificial
addition of carbonate of Uthia. Baths with water of the
same spring were also given ; and the Administration of
the Spas of Baden-Baden are now occupied in preparing
a mother-lye from the water of the Murquelle, in order
to gain so much of the salt that it may next yejtr be
added to the baths. Of all the antarthritic remedies
offered by the springs of Baden-Baden, none have proved
so beneficial as this lithia spring. Dr. Ruef has, in some
cases, at the same time employed the Russian vapour-
baths, prepared from the steam of the hottest spring of
the place, which has a temperature of 155^ F."

Waters of Carlsbad (Bohemia). — A reference to the
analysis in the Appendix will show that sulphate of soda
is the principal ingredient of Carlsbad waters, but carbo-
nate of soda and chloride of sodium are important con-
stituents; in addition to which the high temperature
adds powerfully to their therapeutic influence. In a
certain number of patients a purgative action is induced
by the exhibition of these waters, but in all cases there
is copious diuresis and some excitement of the vascular
system. Owing to the presence of the carbonate of
soda, these waters possess the power of rendering the
fluids more alkaline, and thus, in some respects, they
resemble those of Vichy.

The waters of Carlsbad are employed with most
advantage in gout connected with disturbance of the
stomach, congestion of the portal system, and consequent
enlargement of the liver, with deficient secretions from
the alimentary canal ; in cases, therefore, in which the
disease is more especially connected with an excessive
formation of uric acid. In weakened habits, or when
the kidneys are seriously implicated, or when there is

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heart disease, these waters should not be resorted to, as
they may under such circumstances be productive of
serious mischief.

Dr. Kraus of Carlsbad has kindly given me some addi-
tional information as to the treatment there, which may be
found useful. He says that it is a common but mistaken
idea that the Carlsbad waters are merely purgative.
Their action appears to depend partly on the condition
or peculiarity of the patient, partly on tlie way in which
they are taken. In some cases they cause free purgative
action, but rarely anything like diarrhoea; in many cases,
on the contrary, they cause constipation, and it is necessary
to add some of the Carlsbad salts to the waters. In
some the waters when taken tepid are more active ; in
others when taken hot ; so that each case requires to be

Online LibrarySir Alfred Baring GarrodA treatise on gout and rheumatic gout (rheumatoid arthritis.) → online text (page 32 of 48)