Climate and Residence
While, naturally, individuals display wide differences in their capacity of adjustment to variations in climate and season, there is no doubt that the gouty, as a class, are abnormally deficient in their power of adaptation in this respect. Said Hippocrates in one of his aphorisms, “Podagrici affectus vere et autumno plerumque moventur,” and this peculiar influence of season, viz., the aptness of gout to recur in spring and autumn, especially in its early stages, is a very singular feature.
The increased incidence at these particular periods of the year is, I think, a striking proof of their deficiency in the defensive mechanisms that enable normal persons to withstand with comparative impunity sudden transitions from cold to heat, dryness to damp, and so forth. So it is that rapid changes in the surrounding air, in its degree of warmth, or its motion by wind are fertile of attacks. The east and north-easterly winds of spring account for no few examples, as likewise inadequate protection from cold or damp.
In short, a variable climate is the most provocative of gout, that is, most likely to elicit gouty manifestations in one predisposed thereto. Conversely, stability in climate favours freedom from attacks. Thus some obtain exemption from their gout by removing to a hot climate, others when removed to one of cold, dry character. Doubtless these differences in response hark back to individual constitutional peculiarities.
It is the vigorous plethoric persons, who eat too much, that do well in dry, cold climates. The low temperature and dryness of the air stimulate tissue changes, dispose them to active exercise with consequent increased efficiency of digestion, assimilation, and excretion.
On the other hand, many victims of gout are spare feeders, with feeble powers of digestion and metabolism, and for them a mild, moderately warm and not too damp climate is the more suitable, involving, as it does, less strain upon their capacities of adjustment.
If one may be permitted the generalisation, the ideal climatic conditions for the gouty are low relative humidity, abundant sunshine, and a low rainfall. But, alas! too often, permanent residence in such desirable surroundings is unattainable, and the most that can be compassed is a brief sojourn in some more congenial environment.
Still, some discrimination must be shown in the matter of choice, and the physician, while mindful of the gout, must envisage the individual as a whole; for in advocating a change of climate his hope is that he may remove or antagonise certain noxious influences and coincidently restore the physiological machine as near as can be to a state of functional efficiency.
The former purpose will often be fulfilled by mere withdrawal of the subject for a time from his usual calling and environment. How frequently will simple rest and recreation succeed when medicinal and other forms of therapy have wholly failed! And how largely, may we remark, does the Vis Medicatrix Naturæ work through the medium of things psychic, not physical, to achieve its beneficent ends!
Still, not always is it rest that is needed, and some regard must be had to previous habits. Thus, for the sedentary, repair to a bracing climate is indicated, some inland resort of moderate elevation, where oxidation processes are quickened, and where if they eat more they take more exercise, and so adequate elimination is assured.
On the other hand, for the elderly or old, or those enervated by long-continued gout, a sedative climate must be sought, one marked by mildness, dryness, and equability. Bath, with its low diurnal range of temperature, is eminently suitable for this class of gouty patient, who often stand but ill the, for them, too stimulating qualities of more bracing localities, such as Llandrindod, Harrogate, or Buxton, etc.
Frequently, however, our choice is dominated by some associated morbid affection. Our patient may suffer from a so-called gouty eczema; if so, he must avoid cold, damp places, or windy localities, and, for that matter, sea air often, at first at least, aggravates the affection. Or it may be that he suffers with “dyspepsia,” some catarrhal condition of the alimentary canal, or a “sluggish liver.” For him, then, a dry inland health resort of moderate or high altitude is preferable to one of sea level, which will likely find him drowsy, indisposed to exercise, and a prey to what he terms biliousness.
If renal disease be a complication, he should seek a dry, warm climate, and, if he can, winter abroad, say, in Upper Egypt or Algiers, which, though it is warm and dry, is nevertheless somewhat marred by the wide diurnal range of temperature and the not infrequent cold winds. If, therefore, very sensitive to vicissitudes of temperature, the relatively dry, warm marine health resorts of the Riviera are open to him.
If to go abroad is out of the question, one of the mild southwestern seaside resorts at home is eligible, i.e., Bournemouth, Sidmouth, or the more sheltered parts of Torquay, and Falmouth. Again, if he show a tendency to cardiac dilatation, with or without valvular disease, high altitudes will obviously be unsuitable, and dry, inland resorts of moderate or low elevation should be given the preference.
Lastly, before despatching any gouty subject for a so-called change, it is wise to elicit any personal idiosyncrasies that he may be victimised by. In other words, find out his most vulnerable points. Thus some gouty persons are able to brave cold and damp with impunity, but pay dearly for the slightest indiscretion in diet. They must therefore be warned that no climatic change, however suitable, will absolve from the ill-effects of improper or immoderate eating.
Others again—the majority—are extremely sensitive to atmospheric changes, and such good as they might derive from a well-selected climate is nullified through thoughtless omission of simple precautions against “chills.” In short, the victims of gout can only ensure for themselves the beneficial effects of climatic therapy if, at the same time, they vigilantly shield themselves from what experience has shown to be, in their particular instance, the most fertile extrinsic or intrinsic source of relapses or exacerbations of their disorder.
Choice of Residence.—In these days it may savour of irony to talk of a choice of residence where none is. Still, much of the benefit accruing from a change of air will depend not only on the place resorted to, but the situation of the dwelling or hotel, in which the subject takes up his temporary abode. Thus in inland resorts some parts of the town may lie in a hollow, others on adjoining slopes or plateaux at an altitude higher by some hundreds of feet. Sites like the latter are obviously unsuitable for the victims of cardiac dilatation, etc. Again, where the patient’s condition is such that he must perforce spend a large portion of his time indoors, it is a matter of some moment that the situation and aspect of the building and, more pertinently, the subject’s suite or room be ascertained before he takes up residence.
Apart from sanitary and hygienic considerations, the quality of the cuisine, general comfort, class of society, have all to be thought of, if the best results are to be obtained. They are not unimportant details. How often is the benefit of a stay nullified by uncongenial surroundings, by a gloomy outlook, the fret and jar of ill-assorted or discordant elements, that forbid that cheerful intercourse that does much to restore that sense of bien-être so eagerly sought.
In short, attainment of the best results of climato-therapy can only be achieved through the medium of a closer co-operation between those who practise at health resorts or spas and the patient’s usual medical attendant. But, meanwhile, for most of us, our dwelling place doth rest upon our calling, and we may take this for our comfort that climatic vicissitudes may be greatly mitigated by a well-situated and sanitary residence. I allude, of course, here to a permanent abode, and the gouty, if he enjoy any latitude, should live in a house built on a well-drained gravel soil on a slope, sheltered from the north and north-east winds.
Again, with the question of habitation is bound up the equally important matter of clothing. By our forefathers flannel underwear was deemed the most eligible, despite its low or deficient power of absorption. But, without discussing the various arguments adduced in favour of this or that particular fabric, I would myself favour silk as being, perhaps, the ideal underwear; next to this a single woollen or woven linen vesture, and it goes without saying that, prone to excessive sweating as these gouty subjects are, frequent changes are essential. The feet of the gouty are their weak spot, and, apart from the correction of static deformities, flatfoot, etc., it is extremely desirable that they not only be well shod, but be especially careful not to sit about in wet boots or socks.
For the rest, their outer layers of clothing should be light, warm, easy and not tight fitting. Extremely liable as they are to lumbago and sciatica, they should be careful to enlist a thicker fabric than is usual for the back of their waistcoats; while sufferers from sciatica may, with advantage, insert a silk lining to the seat of their trousers.
Lastly, it is most important that the gouty, and of course all persons, should dress according to the prevailing weather and not according to the time of year. For them, more than any other class of person, to doff summer and don winter clothing for no other reason than some arbitrary date is fraught with mischances, freedom from which would be purchased by a little commonsense.
Exercise
It has been wisely said that “those threatened with gout should imitate as far as practicable and consistent with comfort the habits of agricultural labourers,” for sedentary occupations and idle ways not only favour the invasion of the disorder but hasten its recurrence.
How frequently, indeed, is it the direct outcome of an abrupt change in habits—a hunting man, predisposed to gout, sustains an accident, can no longer ride to hounds and takes to motoring. Unless he forthwith curb his food intake, the disorder overtakes him. Sometimes misfortune proves a blessing in disguise, as in the case related by Van Swieten of an opulent and gouty old priest, who, captured by Barbary corsairs and forced to work as a galley slave, soon lost his gout.
Again, it is notorious that in those in whom the brunt of the disorder falls on the lower limbs, the outlook is more sombre than in those more severely crippled in the hands. In short, capacity for and willingness to take adequate exercise is one of the most potent measures wherewith to fend off the gout. The amount should be in proportion to the age, strength, and previous habits. The exercise should be taken not after a spasmodic but systematic fashion. For erratic, like excessive, exertion often converts the expected benefit into the exciting cause of an attack. The aim should be not exhaustion but wholesome fatigue.
Young and fairly vigorous persons, if previously sedentary or indolent in habit, should take regular exercise, gradually increased. In the middle-aged, especially if obese, it should be graduated according to the capacity of their circulatory organs, and more stress laid on respiratory exercises and dietetic restrictions. For in their instance fatigue or over-exertion is easily induced, often with grave consequences. Also, in long-standing cases, neurasthenic from long-continued pain, it is well to begin more or less tentatively, and in many cases to prescribe a course of massage before proceeding to active exercise. For not seldom such subjects have but a small fund of nerve energy to draw upon.
In the gouty, even the malign influence of bad habits of living is greatly mitigated by active exercise and labour. “The gout very rarely visits the poor man’s cottage.” Nothing can so effectually counteract a predisposition to the disorder, and what Sydenham thought of its value we may guess from his trenchant remarks on horse exercise. “And, indeed, I have often thought if a person was possessed of as effectual a remedy as exercise is, in this and most chronic diseases, and had the art likewise of concealing it, he might easily raise a considerable fortune.”
In conclusion, if healthful exercise of the body is imperative for the gouty, I need scarcely labour the desirability also of congenial and adequate exercise of the mental faculties. Adequate, but not excessive, lest, like Sydenham, it reacts in added sickness. Otherwise absorption in some honourable pursuit will do much to dissipate that tendency to introspection and depression so often born of the consciousness of an ever-constant menace to long-continued health.
General Massage
In judiciously prescribed and skilfully applied massage we have an agent of pre-eminent value in the treatment of gout. Indeed, Sir William Temple—a martyr to the disease—when speaking of the benefit of “friction,” frankly stated that “No man need have the gout who can keep a slave.” In this there is much truth, for the beneficial results of massage are not confined merely to the affected joints or muscles, but, as a result of the improved circulation, waste products are more readily excreted, the nerve centres regain tone, and a general feeling of bien-être is promoted.
It cannot be doubted that general massage of the trunk and limbs accelerates the elimination of the chemical outcasts of metabolism, and simultaneously, by ensuring a more adequate supply of fresh blood to the tissues, must result in an access of renewed vitality. Many, indeed, have adduced experimental proof that such a quickening of the vital processes does ensue after general massage. We should therefore, in elderly or feeble subjects, or in those of sluggish habits, advocate from time to time a course of general massage for its prophylactic effects.
It is the more especially indicated in those gouty subjects prone to attacks of muscular fibrositis—attacks of which are undoubtedly favoured by the retention of the toxic and waste products of muscular metabolism. Nothing, again, so facilitates the dissipation of exudates, nodules, or thickenings in these structures, for the treatment and prophylaxis of which massage is indispensable.
In enlisting the prophylactic action of general massage, it is not desirable that the séance should exceed forty minutes, and it should in all cases be followed by an hour’s rest; to practise it too soon after a meal is inadvisable, and in those cases in which it favours the advent of sleep it is best undertaken in the late evening.
In conclusion, I would urge the importance of more interest being taken by the physician himself in the technique of massage, as I am assured that, if rationally and perseveringly practised, it constitutes one of the most valuable adjuncts in the prophylaxis of gout.
General Hydro-therapy
That hydro-therapy constitutes one of the most effective, if not the most effective, methods of treating gout, is almost a truism, if judged by that most “acid test”—Experience. The particular applications we are about to discuss entail exposure of the whole body. In other words, those measures directed more especially to treatment of the underlying causal state—the correction of that warp of metabolism or auto-toxic state of which the arthritic, muscular, or other lesions are but local manifestations.
It goes without saying that, with this for our objective, there is much need for discrimination in the selection of measures suitable for individual cases, and, naturally, the basis of such differential treatment is thorough physical examination prior to embarking on the course. Yet how frequently on their own initiative do these subjects enter lightly upon a series of baths, mingling stimulant and sedative procedures in haphazard fashion, unwitting that hydriatric measures are capable of infinite harm when misapplied.
For in hydro-therapy the personal equation is of prime importance, varying with individual reactive peculiarities. In short, the character of the response differs widely in different subjects, efficiency or not of the nervous and circulatory functions being the chief controlling factors. Hence accurate appraisement of the reactive powers of the constitution to hot and cold applications is the basis of rational hydro-therapy.
Thus nervous irritability is the outstanding characteristic of some gouty constitutions. They are therefore intolerant of extremes of temperature, and for them sedative or sub-thermal baths are the most suitable.
Others suffer from torpid circulation and sluggish vascular response, and in their instance, stimulant measures, hot or cold, in sequence or in alternation, are indicated. Again, some are obese, and others lean, and while of the twain the former react more feebly, on the other hand, they stand prolonged courses of hydro-therapy more satisfactorily. In contrast, the thin, though they react well, are more readily exhausted, and so apt to suffer from “secondary chill” or other untoward consequences.
Prophylactic Measures.—As we have noted, the “gouty,” more than others, are intolerant of atmospheric vicissitudes. Accordingly, if we would strengthen their defensive mechanisms in this respect, we must endeavour to train them to react more adequately to cold or sub-thermal impressions.
Of the value of thermal applications in chronic gout I am convinced, but, on the other hand, we must not blind ourselves to the value—prophylactically speaking—of their judicious conjunction with sub-thermal or cold procedures. For these latter stimulate oxidation processes, and in chronic gout, according to many, there is deficient oxidation of protein waste, while, apart from this, in the gouty obese there is imperfect oxidation of adipose tissue.
Prophylactic measures to be of any real avail must be continuous, and spas or hydropathic establishments should indeed be more alive to their educational responsibilities in this matter, for the benefits of hydro-therapy as regards prophylaxis are within the reach of all possessed of the convenience of a modern bath-room.
They should be taught to inure themselves by taking daily a tepid bath followed by a cold shower or rain spray. If this be too drastic, let them, while standing in warm or tepid water, briskly rub the rest of the body with a coarse towel wrung out of cold water, into which, if liked, salt has been added to the point of saturation. In this way the tonic effects upon the skin of hypo-thermal or cold applications may be invoked, and thereby its undue sensitiveness is reduced and therewith the liability to subsequent attacks.
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.
Having regard to their radio-active properties, the best results are undoubtedly to be obtained by a combined bath, drink, and inhalation cure. Simple immersion baths, deep or reclining, with or without massive under-current douches, enjoy well-deserved vogue for their general and local effects.
Moreover, as the local douching exerts a sedative as well as a resolvent effect, they prove most useful not only in articular gout, but in the treatment of those frequent concomitants, lumbago and sciatica. Their efficacy is much enhanced by coincident or subsequent massage, and to increase the powers of resistance, such hot baths should be followed by graduated sub-thermal or cold applications.
Sool-Bader, or natural thermal brine waters, exert a similar effect, but such are not available in this country. But cold brine baths—given at temperatures of 98° F. and upwards—are obtainable at Droitwich, Harrogate, and Builth, and are invoked more particularly in long-standing cases with great thickening of the arthritic or related muscular structures.
Again, gouty subjects not seldom suffer with high blood pressure, and our treatment must be modified accordingly. Here we may enlist what are known as Aix massage baths, which tend to lower arterial pressure through the profound influence they exert on metabolism, and the elimination of toxic and waste products. As in warm immersion baths enervating after-effects are apt to ensue unless the tonic-bracing action of a terminal cold application be invoked. On the other hand, in some cases of chronic gout the abdominal musculature is very flabby, with a tendency to visceroptosis and low blood pressure. In their instance, a Vichy bath, inasmuch as it tends to raise the blood pressure, is preferable to Aix massage.
Another powerful method at our disposal for the elimination of waste products is the vapour bath. It is not suitable for the old and feeble, or those with advanced cardiac or renal disease, but it is especially adapted to gouty subjects with harsh, thickened or irritable skin, and those of obese habit.
While the foregoing procedures, generally speaking, are eligible for the more robust type of individual, we must have regard also to those of delicate constitution, whose strength is sapped by long-continued gout, or who show signs of pre-senilism. In such instances, sub-thermal baths (82° to 97° F.) have a great sphere of usefulness. Thus in the presence of high arterial pressure, a course of immersion baths, say, at 93° F., combined with fan douches, and applied according to the Bourbon-Lancy method, are very effectual in reducing arterial tension. Of marked sedative action, such neutral baths are peculiarly eligible also for all types of gout associated with insomnia, irritable skin affections, or showing signs of vasomotor instability.
Moreover, these sub-thermal baths are valuable in articular gout of subacute or lingering character if the douches used are of low pressure, which latter is essential if the joints are sensitive. Their therapeutic action is of course more pronounced in those natural mineral waters which more nearly fulfil the requirements of a neutral bath. Such are possessed in high degree by the waters of Buxton, Ragatz, and Baden-Weiler, the average temperature of which approximates to the point of thermal indifference.
Methods of Local Hydro-therapy
In one form or another, douches have for centuries been used for chronic joint affections. Three factors have to be considered—the volume, pressure, and temperature of the impinging water. The size and form of the stream determine its thermic and mechanical effect, and cæteris paribus, the more massive the volume, the more marked the results produced.
The pressure, again, is a most important factor, as the influence on the circulatory and lymph flow in deep-seated tissues is directly proportional to the force of delivery.
We see, therefore, that in douches we have a weapon of great power for good or ill, and the results achieved will be exactly proportional to the judgment displayed in meeting individual requirements in the matter of their temperature, duration, and pressure.
The space at our disposal forbids entering into great detail, and a few general principles are all that can be enunciated. Thus, while extreme pressures are permissible in selected cases, they are contra-indicated when dealing with regions the seat of pain. In such instances we should always begin with mild measures, viz., a tepid fan or spray douche (80° to 92° F.) of low (4 to 8 pounds) pressure. These later may be replaced by a hot (104° to 110° F.) broken jet, or rain douche, of 10 to 15 pounds pressure, and by such graduated procedures pain will often be relieved.
For the relief of stiffness and swelling alternating jets or sprays are most suitable, the hot and cold douches being each of fifteen to thirty seconds duration. The more remote the extremes of temperature, and the more abrupt the transition from hot to cold, the greater the excitant effect.
Simultaneous massage greatly reinforces the stimulating and absorbing action of douches, which latter also may in various ways be advantageously combined with other local procedures, viz., local vapour, hot air, and electric light baths.
Treatment by Hyperæmia
Enhanced oxidation and destruction of nitrogen-containing waste and toxins being one of the primary indications in the treatment of all so-called auto-toxic states, it is not surprising that hot air baths—both luminous and non-luminous types—are so extensively employed in gout, either for their curative or prophylactic action.
For the practical details of their administration I must refer the reader to special works on the subject, contenting myself with a brief reference to their therapeutic indications. While all gouty subjects at some period of their life-history may be eligible for hot air baths, their use is contra-indicated in pyrexia. Nor are they appropriate if the case is complicated by any irritable skin condition, or in the graver forms of glycosuria. They are unsuitable, too, if there are any evidences of hyper-thyroidism, from which the gouty, no more than others, are immune.
Again, in cardiac dilatation they must be exhibited with great caution, and where extreme, are of course impermissible, as also in the later stages of chronic nephritis. On the other hand, they are eminently suitable for the treatment of fibrositis in gouty persons, especially of obese type, nor does the presence of glycosuria in such association constitute a bar to their use.
Moreover, as a prophylactic measure, they are extremely well adapted to those victims of gout who lead sedentary lives, as to a limited extent they counteract the evil effects of muscular inactivity. Here also, by the judicious use of graduated after-applications of cold or hypothermal grade, the undue sensitiveness of the skin in these subjects is reduced, and their liability to so-called “liver chills” diminished.
In conclusion, it is the proper blending of their eliminative and prophylactic qualities, according to individual needs, that constitutes the key to rational treatment by hyperæmia. These same postulates are applicable also to the various peat, mud, and fango baths, whose action in essence depends on the varying degree of hyperæmia they produce, and to which, in all probability, their well-established efficacy in gouty affections is attributable. That there are other valuable accessory methods of treatment—electrical, hydro-electric, etc.—in vogue at spas, I am perfectly aware, but the number of special works available for reference on this point relieves me of the necessity of alluding to them in detail.