For young and vigorous subjects the thermo-alkaline waters are to be preferred. Of these the world-old Vichy water is the typical example. Waters of this class are powerfully alkaline, being charged with sodium bicarbonate and carbonic acid gas. They contain very little chlorine, and the salts of potassium, magnesium, and calcium are present in comparatively small quantity. Under their influence all the functions of the body are stimulated, and the urine losing its acidity is copiously voided. It is said that while one is drinking these waters an acute attack of gout may be induced through their in fluence. Probably, however, this is largely due to the fact that the Vichy Springs are visited by numerous patients who have postponed medication until it is too late to avert a threatened crisis. But it is certain that these waters cannot be taken in large draughts. By reason of their elevated temperature and composition, they must be taken in moderation, especially at the beginning of a treatment. It is believed by those who are experienced in their use that without such precautions articular symptoms may be diverted to the internal viscera. As a general rule, it is therefore advisable to administer the waters during the intervals between the attacks of gout. Thus em ployed the crises may be rendered less severe and less frequent—the gastro-enteric catarrh that exists in the majority of arthritic subjects is cured, and the general health is thus greatly improved.. Such complications as obesity, arthritic diabetes, and lithiasis are wonder fully relieved by the use of the waters. Sometimes, after a course of treatment at Vichy it is advantageous to take a supplementary course at Vals, where the water contains chlorides in association with sodium bicarbonate. The waters of Royat, containing iron and arsenic, as well as alkaline saline constituents, are especially useful in the cuta neous disorders and mucous inflammations of the pulmonary and gas tro-intestinal tracts. The springs at Neris and La Malou are to be preferred for feeble and nervous invalids who cannot tolerate the stronger waters. In Germany the springs at Ems and Fachingen are to be recommended for similar mucous affections. In the United States there are few purely alkaline waters, and they do not begin to equal the strength of the Vichy waters. The Bladon springs in Alabama; the Congress and the Seltzer springs in California; the St. Louis spring in Michigan; and the Sheldon springs in Vermont, are among the best-known sources of the class.
For patients of a plethoric habit who suffer with hepatic conges tion and constipation, waters of a laxative character are desirable. These are furnished by springs which contain sodium chloride and sodium and magnesium sulphate. Karlsbad affords the type of this class of waters. By reason of their laxative character they are less likely than the Vichy water to produce visceral congestion. They should not be drank during the crises of acute gout; and they are not adapted to the wants of the anaemic and asthenic victims of chronic, arthritism. But for recent cases of a plethoric character they may be prescribed during the intervals with great advantage. The waters of Kissingen, Marienbad, Homburg, PiilIna, Friedrichshall, Racoczy, Wiesbaden, and Baden-Baden represent this class in central Europe.
The Rubinat water from Spain is an excellent purgative. In France, the waters of Chatel-Guyon are highly recommended for the more vigorous patients, while for those who are debilitated the springs of Saint-Nectaire and of Brides are preferable. In America the Canadian springs at St. Catherine's and at Caledonia, the wells at St. Clair, at Mount Clemens, and other places in Michigan, the Sara toga springs in New York, and the Crab Orchard springs in Ken tucky, are among the most valuable representatives of the saline group. In Great Britain the waters of Harrowgate, Leamington, Cheltenham, and Llandrindod are similarly useful. The mineral waters above mentioned produce very little effect upon old uratic concretions about the joints.
For chronic forms of gout with articular deformity thermal waters are most useful. These vary considerably in the composition of their mineral ingredients. Some of them, like the waters of Teplitz, Plombieres, Buxton, Bath, and the Arkansas Hot Springs, contain very little earthy or saline matter; while the Wiesbaden springs, the Glenwood springs in Colorado, and the Hot Springs in South Dakota are rich in chlorides and other salts. The thermal waters of Plombieres, Bourbonne, Balaruc, and Bourbon-l'Archambault in France are highly esteemed for their resolvent power. Many of the thermal springs contain sulphuretted hydrogen, and this adds to their value when employed iu the form of hot baths. The patient should be subjected to massage while in thn bath, and the affected joints should be gently rubbed and flexed, to promote resolution of the uratic deposits. But this active form of treatment is always contra-indicated in cases of cardiac or arterial or intracranial dis ease.
The mineral springs within the area of the United States are very numerous, and some of them possess considerable value in the treat ment of gout and the allied affections. A convenient classification of their characteristics and territorial location is furnished by Beau mont Small (" Reference Handbook of the Medical Sciences," Vol. IV., p. 694). According to this author, the waters that are "found in the western mountainous district, which extends from the Pacific coast almost to the Mississippi River, are chiefly alkaline springs contain ing a few grains of the purgative salines, generally of a high temper ature and strongly sulphurated. Thermal salines, with and without sulphuretted hydrogen, also occur, such as the Utah and Calistoga springs. In the East the highly carbonated and alkaline-saline springs are the most common. The only thermal springs are in Virginia and the South. These are only slightly sulphurated and almost imperceptibly alkaline. In the great paleozoic basin, which formed the bed of the early sea, we naturally find the waters rich in salines. Those containing chlorides are to be found everywhere, hut such as contain the purgative sulphates are chiefly confined to certain districts, as in Kentucky, Michigan, and western New York. In these the active salt is sulphate of magnesium. In this they differ from the purgative waters of the West, which owe their prop erties to sulphate of soda." In Canada the springs are "chiefly saline and alkaline-saline; a large proportion are ferrated and sul phurated."