COLUMBIA LIBRARIES OFFSITE HEALTH SCIENCES STANDARD mi mil mi mi "HX64076342 RA863.5V83 L33 The mineral waters o The Mineral Waters of Vittel Grande Source * Source Salee THEIR NATURE AND USES COMPILED EXPRESSLY FOR THE MEDICAL PROFESSION EDWARD LASS ERE J/MdJiSVrt _ Columbia Sbtfuecritp intljeCttpoflUrttig0rk College of ^Ijpsicians anb burgeons Htfcrarp Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons (for the Medical Heritage Library project) http://www.archive.org/details/mineralwatersofvOOIass The Mineral Waters of Vittel GRANDE SOURCE AND SOURCE SALEE Their Nature and Uses COMPILED EXPRESSLY FOR THE MEDICAL PROFESSION BY EDWARD LASSERE U. S. Agency, 400 West 23rd Street, New York EDWARD LASSERE, Ac;hnt © in CD CONTENTS «-£ Preface Other Conditions PAGE - 4 Vittel Treatment -- - - - - - - -5 Characteristics of the Waters - - - - - - 5 Vittel Treatment at the Springs - - - - - -6 Vittel Treatment at Home - - - - - - -6 The "Grande Source" Water - - - - - - -7 Gout - . _ _ _ _ - _ _ 7 Urinary Disorders -------- 8 Renal Lithiasis _______ - 8 Pyelitis -----_____g Cystitis -------.__ g Vascular Hypertension - - _ - - - -8 9 The "Source Salee" Water - - - - - - -10 Hepatic Conditions - - - - - - - -10 Gastric Disorders - - - - - - - -n Vittel Treatment in Children - - - _ _ _ _i: Urinary System - - - - - - _ _i] Hepatic System --_--___ Digestive System - - - - - - - -11 "Notes on the Uses of the Vittel Waters" - - - - - 12 By H. J. Johnston-Lavis, M. D., D. Ch., M. R. C. S„ etc. Adjuvants in Vittel Treatment at the Springs - - - - 14 Environment - - - - - _ _ _ -14 Balneo-Therapy - - - _ _ _ _ -14 Mech a no-Therapy - - - - - - _ -14 Warm and Superheated Air - - - - - . -15 Massage --------__ je Electric Installations - - - - - - -15 Open-air Exercises - - - - - _ - -15 Dieting ------____ -g Regulation Diets - - - - - . _ - 16 "Some Examples Illustrating Cases of Chronic Toxaemia at Vittel" - 17 By II. J. Johnston-Lavis, M. I)., D. Ch., M. K. C. S., etc. heb Examples Illustrating Cases of Chronic Toxaemia at Vittel" - 25 By if. j. Johnston-Lavis, m. J>., D, Ch., _f. R. c. s., etc. Clinical History of Various Cases treated with the Vittel Waters - - 31 By Dr. F. Constant, 0. Paris, France. PREFACE. THE application of natural mineral waters to the cure or relief of disease involves much more complicated considerations than is sometimes supposed. Mineral waters are a two-edged weapon demanding the most skilled handling. Hence medical men who send patients to mineral-water health resorts should be well acquainted both with the property of the water at the resort selected and with the ways in which it is likely to be used by the colleague thereat to whom they entrust their patients. During the past few years the details of hydrotherapy have been consider- ably modified under the influence of various authorities, including physicists and scientific chemists, as well as medical men. The treatment provided now is not merely curative, but also prophylactic, and may be applied with advantage to children as well as adults. In this connection a statement of Professor Lan- douzy may suitably be quoted: "What is necessary is that the medical profession should learn to take advantage of natural mineral waters and the resources of physio-therapy. If the visitors to mineral-water health resorts included a larger proportion of children, the number of adult visitors would in a few decades corre- spondingly decrease. Those who otherwise might have been visitors would, having been cured in childhood of their original weaknesses, be less prone to disorders of the throat, bronchi, skin, kidneys, liver, and stomach — less affected by those disease-originating diatheses which children inherit from parents, and at present transmit in their turn to their own offspring, because not submitted to the redeeming qualities of natural mineral waters, and thereby enabled to rid themselves of their ancestral defects." It rests, therefore, with practitioners anxious for the well-being of the race to transform mineral-water health resorts into true schools of hygiene, moral, physical, and dietetic — into schools of health capable of correcting both original and acquired defects. VITTEL TREATMENT. CHARACTERISTICS OF THE WATERS. Of the numerous springs at Vittel, two only are generally utilized. These are the Grande Source and the Source Salee, which were declarees d'Utilite Publique (declared a Public Benefaction) by the French Government (Minis- terial decree of Dec. 29th, 1903), being the only springs at Vittel having been considered worthy of that distinction. These springs present the rare advantage of possessing a mineralization which is at the same time sufficient and not excessive. It is sufficient because, contrary to certain so-called medicinal waters, of which the mineralization is two or three times less, or even almost nil, the Grande Source and the Source Salee have a very active effect upon the organism, of which they excite the nutrition and from which they clear away the waste caused by an im- perfect assimilation. Their mineralization is not excessive because they do not present either the inconveniences of waters too highly charged with sulphate of lime, a therapeutic agent of contestable value, but also and especially dif- ficult of digestion, nor the dangers of waters too strongly alkaline, which weaken the organism and provoke, by the alkalinization of the urine, the for- mation of phosphatic gravel, which unites with the uric and oxalic gravel, increasing the volume of the stones. In short, the Grande Source and the Source Salee, thanks to their very slight tendency to liberate free carbonic acid, never provoke dilation of the stomach as do effervescing waters, especially such as are tampered with by being superaerated, a practice which is con- demned by high medical authorities. Also owing to these numerous advan- tages they enjoy the rare privilege of being used as table waters with marked medicinal value. Technically these waters may be described as mild alkaline bicarbonated sulphated waters, non-chloride bearing. The most dominant and characteristic feature is the almost total absence of chloride of sodium or common salt, making these almost unique among mineral waters. This absence of sodium chloride renders them invaluable in all kinds of kidney troubles, arterial and consequent heart diseases, neurasthenia, juvenile epilepsy, etc., etc. 5 VITTEL TREATMENT, AT THE SPRINGS. Vittel treatment is primarily treatment by diuresis, the springs principally employed being two in number — Grande Source and Source Salee. The com- position of the waters they supply, and the indications for their respective use, will be dealt with later on. The average length of a cure, or course of treat- ment, is twenty-one days. The waters, which are of the non-thermal class, owe their action to their temperature, quantity, and mineral contents. When taken on an empty stomach, they stimulate the movements of that organ by bringing about contraction of its muscles; the emptier the stomach, the greater the rapidity with which the water is passed onward to the intestines. There is thus no delay in its absorption and subsequent elimination by the kidneys, the quantity of urine passed being correspondingly increased and the blood thoroughly cleansed. The doses required vary in different individuals and diseases; no general rule as to the dosage would apply equally to all cases. Formerly, when water was regarded merely as a means of washing out the stomach and intes- tines, the quantities prescribed were comparatively large, but they are now, whatever their amount, well within the limits indicated by precise physio- logical knowledge. In short, the doses are always carefully, and in some cases minutely, graduated. In some conditions the water is administered on an empty stomach in the morning; in others, a little before meal-times, so as to promote the secre- tion of purer, and therefore more efficacious, gastric juice. Whatever the dose for the day, it is ordered to be broken up, and the interval between the drink- ing of each fraction prescribed. The length of this varies with each patient and each disease. The commencing doses are always small, and are increased little by little as the system becomes accustomed to the water. Treatment in bed is only prescribed in certain cases of vascular hypertension, which are elsewhere discussed. VITTEL TREATMENT, AT HOME. Since the Grande Source and Source Salee waters of Vittel, "thanks to the stability of their composition are admirably fitted for exportation and use at a distance" (Prof. Landouzy), for those unable to take the cure at Vittel itself, corresponding results may, in a great measure, be obtained by an intel- ligent use of the imported waters, as by treatment at the Resort itself. Being bottled very carefully and under conditions which obviate all risk of contamination, the water keeps indefinitely. No other spa, indeed, has so far attained the same degree of perfection in the mechanical sterilization of bottles and corks and in the securing of asepsis in filling and bottling its waters as that reached at Vittel; the methods there used afford the consumer the maximum of safety in this respect. In a pamphlet published a few years ago, by Dr. H. J. Johnston-Lavis, entitled "Some Truths about Vittel, Con- trexeville and Martigny," speaking of the bottling arrangements at these three stations, he expresses himself thus concerning those at Vittel: "At Vittel, the bottle as it arrives from the factory is cleaned, ster- ilized, then brushed and rinsed in some of the water of the spring, then filled, capsuled, burnished and labelled, all by machinery. The corks are previously sterilized by superheated steam. In fact, some 10 or 12 min- utes converts the glass maker's product into a filled and labelled bottle of the Grande Source or the Source Salee that will keep for months or years, and is of course, free from contamination." Constantly repeated and most carefully controlled researches prove that even after the lapse of two years or more, bottled Vittel water shows no change whatever, and retains all its properties, provided that the bottles are stored under suitable conditions. THE "GRANDE SOURCE" WATER. The first Vittel water to be considered in detail is that supplied by the spring known as Grande Source. Its composition per litre (as determined when application was made to the French Government for official recognition of the spring as one of Public Utility) is as follows: Free carbonic acid o "0475 Carbonic acid in combination ... "3070 Calcium carbonate "2994 Magnesium carbonate '0392 Ferri carbonate 0032 Calcium sulphate o -6288 Magnesium sulphate o • 1923 Lithium sulphate -0004. 8 Sodium chloride \ T Potassium chloride j x races Sodium silicate '0156 Phosphoric acid.... -\ Fluorin I Traces Alumen 1 Magnesium ) Organic matter -0205, 2 Residue at 170 C 1 -2025 The indications for the use of the Grande Source water are considered in the follow- ing paragraphs. URIC ACID STONES ejected at Yittel after a course of treatment by the Grande Source. (Collection of Dr. Patezon, medical inspector.) GOUT. Treatment by waters of the alkaline class is only suited to chronic gout in weak, anaemic individuals, but this is not the case with Grande Source water. It is a typical specimen of the "earthy" class, and as well suited to robust persons, whose attacks take an acute form, as to subacute gout in the weakly. On this point Professor Landouzy says: "A patient subject to acute gout will recover on paying a visit to Vittel, and as soon as his attack is over will see the exudations around the affected joints quickly reabsorbed. On the other hand, a subject of chronic gout in a feeble, anaemic condition should go there as long as possible after his last definite attack, and aim at preventing any further recurrence." But, apart from definite gout, Grande Source water is indicated in sundry allied conditions: 1. In the non-arthritic complications of gout, such as congestion of the liver, neuralgia, sciatica, and bronchial catarrh. On this point it may be men- tioned that Galezowski, the ophthalmologist, advises treatment by waters of this class in conjunctivitis and iritis of gouty origin, especially when recur- rent, and that even varix and phlebitis, when due to the same cause, may be included among the conditions which benefit. 2. In persons threatened with artcrio-sclerosis and exhibiting symptoms such as hypertension, rapid action of the heart, polyuria, or traces of albumi- nuria. These cases require especial care, as anj increase of blood-pressure must be avoided, particularly if a lesion of the aorta has already been es- tablished. 3. In cases of gouty albuminuria associated with the passage of oxalic or uric acid gravel, or when the albuminuria gl merely functional. But even gouty albuminuria of apparently permanent character and associated with oliguria often lessens in amount or disappears altogether. URINARY DISORDERS. Present knowledge of the etiology of oedema, nephritis, and hypertension dictates more care than was common at a time when waters of the earthy class were used chiefly as a means of increasing the permeability of the kidneys. The treatment no longer aims merely at washing out the kidneys and dissipating fluids diffused throughout the tissues. It is only the more lightly mineralized waters of this class that are of service; they withdraw by a process of dialysis some of the sodium chloride impregnating the tissues, and are essential in dechlorhydration treatment. Hence Grande Source water is of value in the following conditions: (i) In albuminuria, when this is due to irritation rather than inflammation of the kidney, as is the case when the primary cause is friction by gravel, especially oxalic acid gravel. Such al- buminuria disappears during treatment. (2) In slight albuminuria, either of mechanical origin or left behind by a bacterial infection or pregnancy, and unaccompanied either by polyuria or any noteworthy change in the general composition of the urine or increased blood-pressure. (3) In cyclical albumi- nuria. And, finally (4), as advised by Castaigne, in cases of chronic nephritis presenting evidence of retention of urea, as distinct from dropsical albuminuria. RENAL LITHIASIS. Renal lithiasis, whether of the uric acid or oxalic acid type and due to causes such as incomplete proteid combustion, or of the phosphatic type and due to local morbid conditions in the urinary passages is amenable to treat- ment by the water of the Grande Source of Vittel. In the first class of case the object kept in view is counteraction of the effect of the arthritic diathesis by stimulating the vital functions, especially that of the' liver, and thus secur- ing more perfect metabolism. In the second, the aim is to promote renal secretion, modify the condition of the lining membrane of the kidneys and urinary passages, and secure evacuation of mucus and sand. According to von Noorden, the favorable action of earthy waters in the former class is due to their holding back in the intestines any acid phosphate of calcium; hence dibasic sodium phosphate predominates in the urine, which becomes less acid. In virtue of the same consideration, the Grande Source water must be regarded as equally indicated in persons of arthritic type, who, without suffering obviously from gravel, pass excessively acid urine which eventually deposits red sand, and who are the subjects either of obesity, dys- pepsia, or migraine. Patients affected with gravel and subject to attacks of lumbar pain are suitable for treatment. PYELITIS. Pyelitis is amenable to treatment by the Grande Source water, both when complicated by phosphatic deposits — the evacuation of these being hastened by the water — and especially when simple and unaccompanied by gravel. In these cases the diuresis effected acts as a kind of natural drainage. CYSTITIS. Cases of subacute or chronic cystitis without obstruction are favorably affected. The pyuria diminishes and the contractility of the bladder improves under the influence of small doses given for a considerable period. VASCULAR HYPERTENSION. There is some degree of inadequacy of renal action in most cases of hypertension, and this makes them amenable to treatment by diuresis. The arterial hypertension is at first merely transitory, the observed pressure being sometimes high, sometimes low. It is in this presclerotic stage, when there is nothing more "than functional evidence of the vascular trouble, and when neither cardiac nor renal lesions so far exist, that Huchard thinks the treat- ment best applied, more especially since the gravel or gout almost always associated with the condition are themselves amenable to the Grande Source water. For some years past it has been observed, it may be noted, that lowering of tension occurs when chlorides or uric acid are freely discharged. Another, but less common, type of sclerosis also improves under Vittel Grande Source treatment — cases of hypertension accompanied by the passage of large quantities of urine containing few solids. In such patients the per- meability of the renal tissues is diminished, and the output of chlorides and of nitrogen compounds is always subnormal. This is the class of cases in which treatment in bed is desirable; the good effect is quickly evidenced by increase in the total renal output both of solids and water, and prognosis may be based on this fact. OTHER CONDITIONS. There are sundry other conditions in which use of the Grande Source water is indicated. The following in particular may be noted: Glycosuria. — In glycosuria associated with obesity, gravel, gout, or other evidence of arthritism, if the sugar is of alimentary origin, it is usual to see it decrease and sometimes totally disappear during digestion. The co-exis- tence of moderate albuminuria is not a counter-indication. Obesity. — In cases of obesity in persons who are distinctly arthritic in diathesis, even though free from its common sequences. In these patients the treatment may be supplemented by physio-therapeutic measures. Dermatoses. — Certain dermatoses of general origin benefit, as also do certain cases of migraine allied in some degree to arthritism by being as- sociated with overfeeding or a sedentary life. yiffm THE "SOURCE SALEE" WATER, BILIARY STONES ejected at Vittel after a course of treatment by the Source Sal6e. (Collection of Dr. Pate'zon, medical inspector.) The other Vittel water is known as Source Salee. Its composition per litre is as follows : Free carbonic acid o '0585 Carbonic acid in combination... 0-4200 Calcium carbonate o -3230 Magnesium carbonate -1294 Ferri carbonate o -0003 Calcium sulphate o, - 6i78 Magnesium sulphate '5805 Lithium sulphate o -0007, 9 Sodium chloride ] ~, Potassium chloride j races Sodium silicate -0307 Phosphoric acid.... \ Lithia (_ „ Alumen X Traces Manganese ' Organic matter -0300, 1 Residue at 170 C 2 7260 HEPATIC CONDITIONS. The disorders amenable to treatment by the Source Salee water are certain types of biliary lithiasis. The following are the types in question: 1. Cases of arthritic lithiasis in persons not constitutionally predisposed thereto, but who present evidence of imperfect or retarded metabolism. 2. Cases of repeated biliary colic; in order to provoke a mild attack during which the biliary concretions will pass on without constitutional dis- turbance. In these cases alkaline waters afford no visible result, but, on the contrary, Source Salee treatment generally ends in the expulsion of the stone, if one exists. 3. Convalescence from biliary colic; the improvement in these is very rapid. The extent to which the Source Salee water favors the secretion of healthy bile can be seen in the subjects of biliary fistula. 4. Mild, slow cases of almost apyretic angiocholitis. In these "mineral-water treatment as an adjuvant to other measures is capable of affording most excellent results.... If the hepatic cellules require specially tender handling, Vittel treatment should be selected." (Gil- bert and Lereboullet: Rap. Con. Franc, de Med. Geneve, 1908.) 5. Biliary lithiasis associated with constipation due to lack of bile. In these cases alkaline-water treatment is distinctly contra-indicated, but that of Vittel Source Salee is especially valuable, more particularly in persons with irritable, easily congested livers. 6. Biliary lithiasis associated with a gouty articular or nephritic mani- festation. The combined disorders can be treated simultaneously, if desired, by the Grande Source and Source Salee waters. 7. Liver disorders in feeble and anaemic persons. Mathieu (in L'Hygiene du Goutteux) has pointed out that in liver cases in nervous, thin, weakly sub- jects the wasting and exciting action of Carlsbad treatment must be shunned, and water of the Vittel type selected. Other hepatic conditions suitable for treatment are congestion of the liver in gouty persons, accompanied by deficient performance of its functions and cholaemia, whether idiopathic or consecutive to infective lesions of the bile canals. GASTRIC DISORDERS. Also susceptible to treatment by the Source Salee water are cases of motor dyspepsia associated with gastric atony and biliousness, and the same form of dyspepsia in gouty persons and those with either ordinary or nerve manifestations of arthritism. The fact that constipation due to insufficient biliary secretion may be successfully treated has already been mentioned. Certain types of muco-mem- branous enteritis, associated either with biliary lithiasis or uric acid retention, also prove amenable to treatment by Source Salee water. VITTEL TREATMENT IN CHILDREN. Arthritism in children is invariably the outcome of heredity. Such children, to adopt Grandmaison's phrase, are born "arthritisable" — that is to say, with a morbid predisposition in the cellular metabolism of certain tissues which, unless counteracted, is bound to manifest itself sooner or later. Hence, if heed is to be paid to the views emphatically expressed by Prof. Landouzy in the passage quoted in the Preface to this brochure, Vittel treatment may well be prescribed for the children of gouty parents, especially those who as infants have presented evidence of their inheritance of the diathesis in question. Among the more special indications are the following: URINARY SYSTEM. (i) Cases of alternating urine, this being sometimes concentrated and rich in urates, sometimes clear and of low specific gravity. It is always a proof of irregular kidney action. (2) Troubles of micturition, including excessive frequency, incontinence, and vesicular spasm. In these cases the urine is almost always abnormal, being either too rich in urates or in phosphates, or too acid. These manifestations of arthritism have been shown by Comby to occur even in early infancy, and to be the cause of the discomfort some babies show in various ways when passing water. (3) Cases of gravel during child- hood and adolescence. HEPATIC SYSTEM. Treatment by the Source Salee is also indicated in cases of biliary lithiasis, though this is rare in young people. DIGESTIVE SYSTEM. rders associated with insufficient secretion of bile and slight hepatic engorgement, such as irregular or perverted appetite, alternating costiveness and i of bowels, and chronic muco-membranous enteritis. As an adjuvant to general hygienic treatment of these conditions, Vittel Waters arc of ^reat value. The same remark applies to migraine and skin lesions in children dependent on imperfect performance of nutritive functions. NOTES ON THE USES OF THE VITTEL WATERS. By H. J. Johnston-Lavis, M.D., D.Ch., M.R.C.S., Engl., Etc. Professor (Fellow) Royal University of Naples. Senior Consulting Physician R. Victoria Memorial Hospital (Nice-Beaulieu). We have at Vittel several waters, and consequently a considerable scope for their use in different classes of ailments. Of late years a great change has come over hydrotherapeutic treatment. The violent, highly mineralized waters of Vichy or Carlsbad, Bath, or Harrogate, etc., are being replaced by milder waters, the effects of which may be a little slower in bringing about a cure, but have the advantage in that cure being more substantial and permanent. They do not expose the invalid to the secondary effects of the more heroic water treatment, and are without the disagreeable after results that so often follow the employment of too drastic measures. This is no doubt the outcome of the change in our habits. Gout fifty years ago was in general a widely different thing from what it is to-day, and so treatment then and now must be different. The Grande Source, almost unlimited in amount, gushes out at a tem- perature of n° C. and practically never varies in volume or temperature during any season of the year. It is par excellence the spring where uric acid and other waste products or toxines and the diseases associated with their presence are treated. Whatever our views may be as to cause and effect of them in arthritism, gout, the gouty state with its near allies or manifesta- tions, neurasthenia, neuritis, neuralgias, sciatica, certain dyspepsias, intestinal catarrh and above all the different kidney troubles, calculi be they uric, uratic, oxalic, and most of the rarer forms of stone or gravel, we are struck by the specific action of these springs in producing the remarkable results that yearly build up the reputation of Vittel. Even a layman who stops a few weeks at Vittel hears quite enough from the patients themselves to convince him of the large number of cures and cases of marked improvement. Chronic forms of nephritis, adolescent albuminuria, cystitis, prostatis, are all amenable to its beneficent action. The age of a man has been aptly defined as the age of his arteries. Of late years the researches of Prof. Huchard and others, including some of the physicians of Vittel, have clearly demonstrated that these waters have a specific action in permanently lowering excessive blood pressure and in the treatment of the troublesome and dangerous disease of arteriosclerosis or hardened arteries. In the first stage the arteries are kept in a state of spasmodic contraction and consequently high tension from the circulation within them of blood, loaded with toxines or poisonous substances. This eventually leads to degenerative changes in the arterial walls with higher and more obstinate, increased blood pressure. Finally from the excessive strain so thrown upon the arteries they either burst and cause an apoplexy, or the heart at last fails in consequence of the endless excessive work thrown upon it by the resistance of these hardened blood vessels to its pumping action. It is particularly in the first stage of this ailment that the Grande Source is of so much use. The water is invaluable in the second stage and affords benefit if used with great care even in the final condition of failing heart. Prof. Huchard and many other physicians have sent numbers of patients here each year, and I find that few o-r none go away without marked benefit. Another type of ailment, neurasthenia, so common nowadays, I pointed out some years ago as being particularly ameliorated by a visit to Vittel. Neurasthenia in my earlier professional days I looked upon as an almost in- curable disease. From the moment that I realized that it was a form of toxaemia or, to put in vulgar parlance, "goutiness" of the nervous system, the whole scene changed and I consider myself very unfortunate if any patient suffering from "nerves" does not go home after a suitable cure at Vittel, adapted to each special case, practically well, or at any rate far on the road to complete restoration. Another ailment which shows marked improvement, I have noticed, among the few cases that have come here more by accident than intent, is juvenile epilepsy. One or two cases that did the cure here completely lost their fits, and others have been markedly improved. Probably the relief of the toxaemic condition, which plays such an important part in epilepsy, and the dechlorurizing effect of Vittel water will explain this. In that condition of chronic toxaemia called "goutiness" the Grande Source has its largest scope. In the articular, muscular and fibrous forms such as lumbago it acts as a specific. It is equally effective in the very varied visceral manifestations such as chronic bronchitis, some forms of asthma, some liver and stomach ailments. In neuritis not only does it render great service in the gouty form but finds its use in chronic nerve inflammation from other causes, such as malaria, alcohol, etc. Finally many remarkably resistent skin diseases are vanquished by a cure at Vittel. Its continued use as a table water, far from presenting any inconvenience whatsoever, is eminently favorable to the stomach, the secretions and the muscular tone of which become improved. The Source Salee is composed of the same elements as the Grande Source, but much more higly mineralized in magnesia. It derives its reputation from the marked curative effects it has in different ailments of the alimentary canal. Flatulent dyspepsia often quite disappears after a short course, and the same may be said of mucous or membranous colitis where it may in addition to drinking be used for intestinal lavage with marked benefit. Chronic constipa- tion cases and those of recurring appendicitis have found much benefit by its use. It is however in its influence on the liver that the therapeutic value is most strikingly evident. Liver congestion, whether due to alcohol, sedentary habits, malaria, Malta fever or other causes, rapidly improves. The number of cases of jaundice that are cured and of gall stones that are got rid of every year by its use brings number of victims of that terrible complaint to Vittel each season. Certain forms of diabetes of hepatic or pancreatic origin are quite cured by the use of the Source Salee, and in consequence of its power of re- moving abdominal congestion it is used with much benefit in piles and in convalescence from malarial and other tropical ailments. Large numbers of obese people resort to it to reduce their weight. Finally in certain forms of chronic bronchial catarrh and asthma, probably of a gouty strain, marked improvement follows its use. The water of the Source Salee, laxative but not purgative, exercises an elec- tive action upon the liver, the more precious because it does not provoke any symptoms of anaemia or weakness, but is on the contrary very well tolerated by the organism and particularly by the stomach. Let me further remark that the water of the Source Salee is not at all salt, but on the contrary very agreeable to drink. The bicarbonates of lime, of magnesia, of iron and of lithine give it tonic and depuratory properties which render it digestive and make it a very agreeable and salutary table water; mixed with wine which it does not change in any way, it counteracts the acidity of the liquids in the stomach, excites the appetite, stimulates the digestion, and maintains the regularity of the functions of the liver and of the intestines; it is specially recommended to women whose sedentary habits predispose them to debility of the digestive tube. This incursion into the scientific domain may be concluded by the remark that the Vittel waters keep remarkably well in bottles, and that they have pre- served up to the present their superiority from a bacteriological point of view, verified in 1894 by the Aca6 only exceptionally that the regulation diets do not suit a patient, and special Arrangements have to be made for him; in such cases his meals are prepared according to the specific instructions of his medical attendant. REGULATION DIETS. To facilitate the preparation of regulation diets, each_ visitor needing to "be dieted is handed by his medical attendant a list, on which is marked what iood materials are suitable for him, or otherwise, and this in his turn the visitor hands to the head waiter of his hotel. The value of the system of Vittel has been so well demonstrated that it "has now been adopted at some other health resorts. The regulation diets give rise to no difficulty, the menus proving so acceptable to the patients that when their time at Vittel is up they are quite prepared to adhere, if need be, to the same form of food for as long a time as may be desirable. 16 (Reprinted from the British Medical Journal of July 23rd, 1910.) SOME EXAMPLES ILLUSTRATING CASES OF CHRONIC TOXEMIA AT VITTEL, By H. J. Johnston-Lavis, M.D., D.Ch., M.R.C.S., etc., Professeur Agrege, Senior Consulting Physician to Q. Victoria Memorial Hospital, Nice: Consulting Physician to the " litablissement," VITTEL. Perhaps in the whole history of the growth of a spa or hydro-mineral station none can compare with the remarkable rapidity with which Vittel has jumped into fame. Ten years since it was known to comparatively few phy- sicians, and ranked as a fourth or fifth rate station so far as its resources and number of visitors were concerned. It now stands in the very first rank. I have practised there seven seasons, and done two cures there myself annually, and may, therefore, claim to speak with some experience. I propose to select a few of my cases from one season's (1909) practice, and to point out the results as an illustration of the beneficent action of the cure in some- what varied ailments. The cases of ''physiological disequilibrium" and ailments that are relieved by Vittel treatment, of however varied facies, may all be summed up as the result of chronic toxcemias due to either perverted nutrition, defective metabolism, or incomplete elimination. This condition, which we English physicians denominate as "goutiness" and the French medical man as arthritique, is ill expressed by such terminology. All originate in an excess of one or more of the normal constituents of the blood or the presence of abnormal ones. When we look at these different disturbances of the physiologi- cal balance we shall all the more clearly appreciate the close association of many different ailments. We shall also be able to comprehend how a cure such as Vittel is one of the most effective and rational methods of restoring physiological equilibrium. Who can draw the border line between acute and chronic gout, calculosis, some forms of nephritis, arterio-sclerosis, neurasthenia, asthma, chronic bron- chitis, some dyspepsias and entero-colitis, many skin diseases, neuritis, some rheumatisms, etc.? When I have at other times sustained this thesis, critics have held me up to ridicule. My answer has been, Think over it, and tell me why we so often find several such states associated in the same individual at once or alternating with each other, and why the same cure with suitable modifications is so ef- ficacious in relieving or curing each of these troubles. All the analyses are of the entire and carefully collected quantity of twenty-four hours. They are made in my own private laboratory, fitted with the most modern and approved apparatus by my analyst, Dr. Burrais, of the Pasteur Institute. He knows nothing of the cases, and is therefore quite free from any personal equation modifying the result. All the results are cal- culated on the personal equation of each individual based on weight, height, and age. Where extraordinary results are obtained, both of us repeat the determination. All calculations are based on the personal coefficient. I have much pleasure in thanking him for his valuable and skilful assistance. Case No. i. J. M., aged 58, 6 ft., weight 77 kilos, sent by the late Dr. Radcliffe Crocker. Has suffered for years from eczema on neck, fingers, toes, and fork of legs. He complained of feeling stiff in his movements, lacking energy, and always tired. Has also patches of psoriasis on knees. Two fingers and one toe sup- purating around nails, the region of which is red, swollen, and angry. There is no syphilitic history. The son is a fine specimen of an officer in the Guards, wife in good health. Patient has always been temperate, has fairly good 17 digestion, but takes an aperient every morning, "which keeps him all right." His skin acts freely. He is otherwise a strong, healthy man. He has "been twice to Homburg, and three times to Schinznach, with little benefit. On July 18th, day after arrival, had a mean blood pressure of 135 mm. His urine is represented in the diagram illustrated here, which is remarkable by the enormous amount of solids, composed of all the elements of the urine, but specially chlorides, which were 73 per cent, in excess. His urea-uric acid coefficient is sensibly normal, but both are increased nearly thirty per cent, above what they should be. After a few days he was drinking 1.800 c.cm. of Grande Source before breakfast, and 900 c.cm. in the afternoon. The skin was kept active with baths at 36 C, and a low semivegetarian diet ordered, excluding salt as much as possible. Another twenty-four hour urine analysis, made on August 9th, one day after the cure was stopped, shows a remarkable change. The curve has the same general form, but approaches quite near to the normal line. Solids have fallen from 204 to 125 per cent., acidity from 144 to no per cent., urea from 128 to 90 per cent., uric acid and chlorides to normal, and phosphates to 9 per cent, below normal. 58 > (3 2 a .a o a to ^ o ^ ^ > to < P » 2 S 3 o o m- -f-to- % \— — — — — — __ — — — ( — Jl- - — — 9& -— — — — — — 80 &- 60 — - — \S 7* — — £0 .- — — — aH J. M., July 20th, 1909. Traces of some reducing material ( ? glu- cose). Slight traces of true and modified biliary pigments and of scatol. Abundant deposit of urates and some pavement epi- thelium. Purins 0.518 per 24 hours. August 9th, 1909. True biliary pigments in traces, as also faint reaction of scatol. Urates and cells much less. Purins 0.689 per 24 hours. Simultaneously with this all his feelings of stiffness, loss of energy, etc., have disappeared, and all his skin lesions are rapidly healing. I think we have, here a case of excessive assimilation which led up to a state of autointoxication in which the skin was most affected, but he was on the verge of an outbreak of joint, muscular, and nervous trouble. The lixiviating effect of a rapidly absorbable and rapidly excretable non- chloride-bearing waters is striking. The purin bodies as a whole seem to have increased at the end of the cure. Whether we can interpret this as increased production or increased excretion of a retained stock could only be determined by ulterior analyses, which unfortunately could not be obtained. The following three cases I have chosen because they consist^ of father, mother, and adult daughter living under sensibly the same conditions, and furthermore that, as they enjoyed Vittel so much, they stopped on for some weeks after their cure, and the second urine analysis was made at a considerable interval after their "cures" had stopped. These are rare opportunities, and I think worthy of study. 18 Dr. Curgenven, who sent them to me, says: "Mr. S. had an attack of car- diac weakness and irregularity about two years ago — a very irregular pulse, high arterial tension, a tendency to dyspnoea, and a dilated stomach; this was caused, I think, by living at too high a pressure, and too generous a diet. With rest and careful dieting he soon improved. A year ago he had a mild attack of basal pneumonia, and he has occasional attacks and threatenings of lum- bago." Case No. 2. The patient, Mr. S., is a hale and hearty looking man, aged 60. His digestion is fairly good, except for a little flatulence; the bowels regular. Car- diac area faintly increased when the heart is working at its normal rhythm. When I made my first examination, on July 23rd, his pulse was running at an almost uncountable rate. After various attempts and dodges I made it 192. While making notes of this and other observation, occupying about three minutes, I returned again to feel the pulse, when to my astonishment it was a steady, vigorous beat of 72. His mean blood pressure was 140 mm. He himself attributed his cardiac condition to extra smoking, he having filled in all the time of travelling by doing it. He was suitably dieted, and alcohol, tobacco, tea and coffee restricted. At the end of three weeks all his cardiac .2 ° > on < P E> P » > s ° 9 .a o 3 a: G - \x/o pw m no, //& •J6& tSP /to 1» [j:o 1& — — A/0 2oo. m t?o .'60 l / 1 1 — — — — / __- ■/ ■ a> ' ' * •\ / 9°- (,0 , — — to 60 - \. ^~ — — — - — — — Mr. C. S-, July 25th, 1909. Modified biliary pigments fairly abundant ; indican marked ; scatol slight traces. Purins 0.798. Abundant crystals of uric acid and urates, and also oxalates. Some epithelial cells. August 23rd, 1909. Modified biliary pigments normal ; indican fairly marked: scatol traces. Purins 0.717. Irate of soda, very few oxalates, and epithe- lial cells. symptoms had disappeared, his digestion was all right; he expressed himself as feeling quite well. His pulse was still at 72, but his blood pressure had fallen to 115. Several days after stopping the cure this favorable state persisted. The urine analysis before the beginning of the cure sItjdws a large excess of nutritive substances and their waste products that the organism was making a great effort to excrete. In the urine analysis after the end of the cure we see that the solids, which were 133 per cent., have fallen to just below normal. The acidity has been but little reduced, only amounting to 12 per cent. less. Urea was reduced from 127 to 8'j per cent., and uric acid to normal. Before the cure urea was much higher than the uric acid, whereas after the ratio was reversed, showing the great utility of the waters in restoring the proper ratio of these two bodies; in fact, this is almost universal, and clinically I have always found that when marked benefit has accrued this has been the case, and where absent the cure has been of less use. The chlorides and phosphates had fallen considerably below normal. Diet will explain the former but the latter is more difficult to interpret. Here we have an illustration of four distinct elements leading to chronic mia — exc noking, alcoholism, feeding, and mental activity. This 19 led to general circulatory spasm, in which both arteries and heart were affected. That true arterio-sclerosis had set in is disproved by the rapid fall of blood pressure under treatment, but no doubt a continuance of the patient's mode of living will soon lead to irreparable artery and heart changes. Case No. 3. Mrs. S., wife of the last patient, aged 45, of slim build, is congenitally par- tially deaf; is a very nervous woman, partly due to that defect; gets bad rheumatic pains, especially in shoulders, and stiff neck, which are specially excited by champagne and strawberries. She has occasional bad headaches but is a great cigarette smoker, and has marked arcus senilis. Heart sounds normal except that aortic valves closed with a slight clang. Has had several children living, and two bad miscarriages and fibroids. Menopause at 42. Digestion is good but has to take cascara. Sleep moderate, perspiration very free. Takes plenty of exercise — golf, etc. Urine analysis at commencement of cure shows solids and acidity too high, urea 15 per cent, below normal and uric acid 47 per cent, above — a very great disproportion. Besides the cure she had some general massage with Vigorax, a dietary in which fats and oxalate-bearing foodstuffs were excluded. The result of this was a vast im- provement in her health — she became less nervous, her pains disappeared as > OQ < P P > 0. — . W43 — — — ® * 166 m 120 — — -• — — A ■w'S to / \ § 3 / V — — /A? y a^. 1 *£ f s OS "3 < u P p .a 5 O > O < u u P 3 .a i/0 sat m m - 2» ISO — — — — — ■ — — — — — - If* I3C 110 — — — — /St no — — A /tO- / no Qf \l ~ \- 40 70 V - _; — ffl _} f — i \ fp J v /tl ifi? 1 J Miss S., July 25th, 1909. Both true and modified biliary pigments abundant ; no indican, but scatol abundant. Purina 0.244. Urates abundant, large crys- tals of uric acid and some small oxalates and numerous pavement cells. September 1st, 1909. True and modified biliary pigments slight traces, and traces of scatol only. Purins 0.664. Urate of soda, rare crystals of uric acid, no oxalates. The patient is a small salt eater, probably in harmony with a defective assimilation of salt. The phosphates are also 34 per cent, below normal. The urine is burdened by urates, uric acid, oxalates, biliary pigments, scatol, etc. The second analysis, made some time after the cure had finished but with the patient otherwise living under exactly similar conditions, shows a curve much more approaching the straight line representing normal, though still showing defective assimilation, but to a much less marked extent. Biliary pig- ments and scatol had markedly diminished, but strangely the purin bodies were nearly tripled, probably from some exogenous source. The further diminution in chlorides was probably partly due to diminished intake and con- siderable losses by the skin, as the patient was doing several hours of tennis besides being massaged. During the cure her weight fell from 79 kilos to 77-450, and continued to diminish, but I have no record of what it really was on her departure from Vittel. She declared herself perfectly well, much more capable of energy, and all her functions in good order. In this case we have another example of perverted assimilation and defec- tive metabolism where the part most assailed seems to have been the adipose tissues. Case No. 5. Miss B., aged 24, had malaria as a child, but has had no traces for many years. As a big girl had eczema very badly, but that has gone long since. Jbour years since had "neuritis" in the right arm, supposed to be due to tennis. No other region was involved. She is nervous, neuralgic, rheumatic, has some fullness of the eyes not amounting to exophthalmos, but no other thyroid symptoms. Her digestion is described as perfect, bowels fairly regular and general health very good. T j h ^ Urine anal y sis be fo r e the cure proved to be one of the most remark- able I have come across. The solids were en masse about normal though the volume was 54 per cent, above. Acidity was 39 per cent, below normal and urine 36 per cent, below, whilst the amount of uric acid reached the astounding > to < P '2 3 O a a T3 '3 u Ph t> CO <1 .° ° p p P. O A A U Oh Miss B., July 31st. Traces of true and modified biliary pig- ments, and also very slightly of scatol. Purins, 0.380. Urate of soda. Great num- bers of epithelial cells. August 20th, 1909. Biliary pigments, true and modified, very abundant, as also scatol. Purins, 0.904. Urates and epithelial cells abundant. figure of 116 per cent, above normal, chlorides only just 10 per cent, below, and phosphates 41 per cent, below. In the second analysis, a day or two after the cure was finished, the urinary curve approaches sensibly to that of normal, acidity is now only minus 24 per cent, and urea 18 per cent, below normal, a gain of 18 per cent. Uric acid has fallen practically to normal— plus 8 only. Still, it is too high for the amount of urea, and I think another week or ten days' cure would have been advisable. Strangely, with this enormous output of uric acid her blood pressure was but 120 mm., with a capillary reflex of 3^2, and pulse of 80. At the end of the cure, with the enormous debacle of uric acid, her blood pressure was reduced to 115, which I look upon as normal for my apparatus. At the end of the cure she described herself as perfectly well and vigorous — fit for any undertaking. The great increase of purins is again an illustration of the inscrutability of their amount in relationship to other physiological processes. Case No. 6. The next example I propose to put before you is interesting from several points of view. He is a typical example of that fat form of Frenchman that the English caricaturist delights in; secondly, he is mayor of the town, and has never drunk an}- other water but Vittel, though that appears to have been a most rare occurrence; lastly, he has been and is a most intense brain worker, always living under high pressure. He is a big and rapid eater, could not be called intemperate, but drinks heartily and takes no physical exercise. I have known him for years, and foresaw what was coming. He is jovial, good tempered, with his enormous charge of work as a busy lawyer, administrator of the town, and magistrate. Mons. H. G. rises at 5 a. m., writes at his desk till 8 a. m., then takes cafe-au-lait, one cup and a roll. He continues the work at his office till midday and then eats a good lunch with wine followed by black coffee. In the afternoon does either office work or goes in his motor car to dif- ferent clients of the region for business, and takes during the afternoon a black coffee and two or three glasses of beer. At 7 p. m. he dines, usually with a soupe-au-lait, with much bread, noodles, rice, and other farinaceous food. After dinner plays cards or other house amusements; during the season goes almost nightly to the theatre. Most of >■ to o ft > 03 «0 £> £> o a J3 o C3 ?. 166 m m — — — — tip A — — — — — 2P0 /earing water, such as Vittel. If by a Buitable diet we reduce the diurnal amount of sodium chloride, which we will put at 12 ^rams, to a practically accessible amount of 6 grams, we give our cellular structure! a chance of giving up to the partly demineralized 25 blood serum their store of uric acid and other toxic substances. At the same time our kidneys have a reserve energy for excreting their uric acid and other toxic substances to the equivalent of the diminished 6 grams of sodium chloride. This analogy will, I hope, make clear the mechanism of the lixiv- iating effects of such a mineral water as Vittel. Case No. i. Mrs. C., aged 49. Blood pressure 140 mm.; capillary reflux 3; pulse 58; weight 72.200 kilos. When young had lung trouble, but has been gouty for three or four years, which, she says, is markedly hereditary. Last Christmas,, after exercise, had dark water and a little pain, followed by rigors and giddi- ness, and finally renal colic. Shortly afterwards the stones dropped into the bladder under the influence of Vittel Grande Source, which had been ordered her. In a few days she passed two small uric acid stones. She is a "good eater, but temperate in alcohol; her digestion is good, ex- cepting for a little flatulence; has been constipated for some time, and has a thoroughly inactive skin. She has a fair sleep, but is a great dreamer, and has a bad mouth in the morning. She came to Vittel feeling generally "down" or "seedy." The first urine analysis portrays the reason of this, as well as some remaining catarrh of the urinary passages. The urea-uric acid ratio is much disturbed. In addition to six glasses of Source Salee in the morning, and three of Grande Source in the O o .a 3 *9 • III "S 03 ; pulse 60; weight 64.650 kilos. Has always suffered from irritability of the bowels, with con- stipation and occasional diarrhoea. Spasmodic calls and mucous diarrhoea very slight. His digestion is good, he does not suffer from headaches, but always dreams. He is obviously neurotic. 26 He came to Vittel because he suffers from tendinous fibrosis, which attacks any group of muscles that are put to any new or special use. He exhibits large nodes on tendon sheaths at wrist, etc. The first urine analysis shows an excess of solids due to too much chlorides, acidity a little raised, urea normal, but marked retention of uric acid, so that the ratio of urea to uric acid is much disturbed with imperfect phosphatic assimilation. He was ordered a relatively low chloride-bearing diet, as free as possible from rich, xantho-uric-bearing foods, six glasses of Source Salee every morning, and three glasses of Grande Source in the afternoon, every alternate day a vapor bath and massage under water, to be followed by a rub down with Vigorax. Unfortunately, he was unable to afford but a little over a fortnight for the cure, notwithstanding which he declared himself as feeling much better, and the nodules on the tendon sheaths at the wrist had much diminished. The second analysis, made while still drinking the water, shows a much greater ap- proach to normal, a great rise in the elimination of uric acid, so that the ratio of urea to uric acid was restored, and even slightly temporarily reversed, and the phosphates were rising. This case had been treated by all sorts of imaginable drugs with little good, yet the improvement at Vittel was striking, considering the short time in which it could be carried out. o a C m *2 o c ®.2 > o ^ o 8 a •m § — ® a 230 240 230 220 210 200 190 180 170 160 ISO 140 130 120 110 Kormj) 90 80 70 60 60 v. • s. A U. U. A. C. P. A. " — iSv Jh- — ■ — — = Z - ^- \- £ \ 60 | Case ii. — Dr. H. August 1st, 1910 ; Specific gravity 1018. Traces of biliary pigments. Indican fairly marked. Purin 0.028. Numerous pavement cells and some sodium urate. August 15th, 1910: Specific gravity 1009. Sodium urate, a few leucocytes, and epithelial cells. Purins 0.328. v, Volume; s, solids; a, acidity; u, urea; q a, uric acid; c, chlorides; P a, phosphoric acid. I take this to be a case of toxsemia of rheumatic facies, probably of in- testinal origin, that, were one able to carefully study the intestinal flora, might be definitely classed, and perhaps even treated by an auto-vaccine. Case No. 3. .Major M. C, aged 42. Blood pressure 135 mm.; capillary reflux 4; pulse 70; weight 115.100 kilos; height 6 ft. 4 in.; is a big, powerful man. In 1902, in South Africa, had bad headaches, which continued till 1905, when al- buminuria was detected. The following winter went to Egypt, and most of the summers since has gone to Contrexeville. He never had scarlet fever, but typhoid as a child, and also malaria. His father died of Bright's disease. He was put on vegetarian diet when his albumen was first discovered. His digestion is good; he now eats fish and chicken, and when abroad veal. He is a heavy smoker (pipe). His headaches are relieved by aspirin, and he takes Hunyadi for his constipation. Has had acute gout in toe. The urine analysis madi the cure shows marked oxaluria, granular 27 cylinders, and 2.08 grams of albumen in the twenty-four hours. The patient wished to be reduced in weight, and the following was therefore the dietary ordered: "Avoid raw and cooked fats, greasy dishes, fried articles, salt and salted foods, pastry and farinaceous food, sweets, gravies, sweetbread, liver, kidneys, rhubarb, sorrel, spinach, asparagus, vinegar, etc." This would hardly be considered an ideal diet for an albuminuric patient, as he was reduced to rather a highly nitrogenous diet, with some vegetables and fruit. Nevertheless his blood pressure fell to 120 mm. Hg.; his capillary reflux from 4 to zA, his pulse ranging from 66 to 70. His weight steadily fell to in kilos — that is, a loss of 4.100 kilos, or 9 lb., in eighteen days. Simultaneously his daily output of albumen was about half of that on his arrival. He took alternately daily a warm immersion bath for twenty minutes at 36 C. and a massage under water at 42 C. He felt much better. The marked acidity of the urine had become negative; the urea to uric acid ratio was restored. At the height of his cure he was drinking seven glasses (half-pints or 300 cm.) of Grande Source before breakfast, which represents, amongst its other constituents, a considerable amount of lime salts, and yet his oxaluria and cylindruria had disappeared. I have chosen this case as a type of one of the low-tensioned toxaemia albuminuric, and above all to illustrate how unfounded are Dr. Benjamin Moore's conclusions as to the injurious effects of calcareous waters in oxaluria. You will remark that this is a renal case without much hypertension, though "18 8o w d ISO 140 130 120 110 Normal 90 80 70 60 50 4^. 8. A._. U. ...y : A.. c._ P. A. V- — ~f— X* w — "^s^ -J- Case in. — Major C. August 13th, 1910: Specific gravity 1023. Albumen 2.08 grams per twenty-four hours. Traces of true and modified biliary pigments. Purins 0.696. Large uric acid crystals, some cells, large oxalate of lime crystals very abundant, and some granular cylinders. August 31st, 1910: Specific gravity 1022. Albumen 1.155 grams per twenty-four hours. Purins 0.789. Sodium urate very abundant ; a few large crystals of uric acid in macles and rosettes, a few pure epithelial cells. No oxalates or casts. V, Volume ; s, solids ; a, acidity ; u, urea ; u a, uric acid ; c, chlorides ; p a, phosphoric acid. no indications of any heart lesion could be found. I think we can interpret this case as one of imperfect metabolism and damaged renal structure which, by suitable lixiviation with a non-chloride bearing water, is soon restored to approximate normal, and might be so entirely if we physicians were not so often subjected to such curtailment of the time given to the cure by the patients themselves. Case No. 4. Mr. H. N, aged 55. Blood pressure 290 mm.; capillary reflux 2> X A\ pulse 58; weight 67.700 kilos. ' Has suffered from albuminuria for years, neuralgias, lum- bago, and from time to time oxaluria and much uric acid sand. Is a temperate man, both in food and drink; somewhat sedentary. He had been a patient of mine before, and had been warned to limit his salt food, which will explain the low quantity of this in his urine analysis. The only immediate complaint he had was bilateral nasal neuralgia. The first urine analysis, the day before the commencement of the cure, shows excessive assimilation, though the urea to uric acid ratio is normal; his chlorides are low from intentional chloride starvation, and some phosphaturia is present. Biliary pigments and indican and scatol are much in excess. As he was obviously the type of hypertension of renal origin, his blood pressure was frequently noted during the cure. 28 The following are the records: July 25th. Blood pressure 290 mm.; capillary reflux $ l / 2 , pulse 58. July 30th. Blood pressure 240 mm.; capillary reflux 3 l / 2 , pulse 58. August 5th. Blood pressure 245 mm.; capillary reflux 3 l / 2 , pulse 58. August 10th. Blood pressure 240 mm.; capillary reflux 3 J/2, pulse 58. August 14th. Blood pressure 215 mm.; capillary reflux 3, pulse 62. This is a striking example of what can be done in reducing blood pressure in a hypertensionist of renal origin. Simultaneously with this his albumen fell from 1.80 grams per diem to 0.425 gram, or less than a quarter of what it was. Curiously his urea has somewhat augmented, but there has been a tre- mendously lixiviating effect on the uric acid, while the phosphaturia has dis- 160 150 140 130 120 110 Norma! 90 80 70 60 v. 2^ s. A. U. U. A C. P. A. — -f~ -"—" ~-C_ y /-"" — V _ _. ._ Case iv. — Mr. H. N. July 27th, 1910: Specific gravity 1018, Albumen 1.80 grams per twenty-four hours. True biliary pigments slight, but urobilin rather abundant, as also indican and scatol. Purins 0.802. Some rosettes of bicalcic phosphate, sodium urate, some crystals of uric acid, some leucocytes and epithelial cells. August 15th, 1910: Specific gravity 1022. Albumen 0.425 grams per twenty-four hours. Traces of reducible matters and of true biliary pigments. Indican and scatol marked. Purins 0.540. Some urates, uric acid, and a few leucocytes, v, Volume ; s, solids ; a, acidity ; u, urea ; u a, uric acid ; c, chlorides ; p a, phosphorio acid. appeared. What the kidney lesion may be is doubtful. I have notes that in 1909 be had some cylindroids and kidney cells in the urine, but in 1910 we could find no trace of either. I have just seen the patient (April, 191 1). His blood pressure has risen in part — 245 mm., and also his pulse, 76 — but he walked quickly uphill to my villa just after lunch. Case No. 5. Rev. J. W. R., aged 68. Blood pressure 165 mm.; capillary reflux 3; pulse 80; weight 83.580 kilos. Had psoriasis some years since. Has had nasal It .3 S3 ^■30 a_ S« X 140 130 120 HO Norma) 90 80 70 60 50 40 30 v. _a_ A u. U. A c. P. K~ .a ** a 9 1-^ y- 6 9 *=£- ^r— <& — ^ Case v. — Rev. J. \V. R. August 13th, 1910: Specific gravity 1024.5. Glucose 10.35 grams per twenty-four hours. True biliary pigments sensible. Indican and scatol marked. Purins 0.391. Numerous crystals of uric acid in rosettes and isolated some leucocytes. August 22nd, 1910: Glucose 3.10 grams per litre after a meal. September 1st, 1910: Specific gravity 1028. Glucose nil. Faint traces of indican and scatol. Purins 0.319. Large and small crystals of uric acid. Very rare leucocytes. v, Volume; 8, solids; a, acidity; u, urea ; D a, uric acid; c, chlorides; p a, phosphoric acid. catarrh for many years, and lately bad rheumatism in arms and back. Last August had bronchitis. Is a moderate eater, his digestion is fairly good, but he has suffered from dyspepsia, for which he got much advantage from Burroughs, Wellcome and Co.'s laxative tabloids and y 2 grain of calomel weekly. Has been a golfer for twenty years. He gets dripping wet from perspiration before the 29 ninth hole is reached, and used to remain soaked till he changed for dinner. Three weeks since had a bad blow over liver from a motor car. On his arrival he was markedly depressed and neurasthenic, said he was no longer able to do his work, talked of retiring, and was much troubled in consequence; doubted whether any cure could save him, etc., was too obese. The first urine analysis showed a very fair ratio between the different normal elements, though all were very much below the average. What, however, was unsatisfactory was the presence of 10.35 grams of glucose per diem. His diet was suitably modified, and he soon worked up to nine glasses per diem of Source Salee. He had a massage under water every other day at 42 C, followed by a rub down with Vigorax. Eight days later he felt much better, and we found 3.10 grams of glucose per litre. On September 1st he felt quite fit to return to work. His blood pressure had fallen to 145 mm., with same capillary reflux and pulse. He had lost 3.280 kilos in weight, or over 7 lb. An analysis showed a marked improvement with a rise of all the elements. This is specially remarkable for the urea and phosphates, though the uric acid was still in part retained, especially as his diet was naturally rich in nitrogen. The chlorides insufficiency is due to privation in his diet. His glucose had fallen to less than a third in the twenty- four hours (3.10 grams). This is a good example of glycosuria, neurasthenia, obesity, and visceral goutiness — four forms of toxaemia with some hypertension, all cleared up in a cure of less than three weeks at Vittel. 150 140 130 120 110 Normal 90 80 70 60 50 40 .,v.„ — &._ _A— _W,„. yJL. c. _P.A._ ^ — — -/ y 7 — .. _. ......... „„ Case vi. — Mr. T. August 23rd. 1910: Specific gravity 1029. Traces of albumen and glucose. True biliary pigments sensible and traces of the modified, also traces of indican. Oxalate of lime in great abundance, but small. Uric acid crystals. Purins 0.352. V, Volume ; s, solids ; a, acidity ; u, urea ; u a, uric acid ; c, chlorides ; p a, phosphoric acid. Case No. 6. Mr. T., aged 22. Blood pressure 145 mm.; capillary reflux 4; pulse 68; weight 64.100 kilos. An otherwise healthy young university man, has suffered from intense seborrhoea capitis for sixteen years, and for a long time a lichenoid growth extending out on the groins and some inches down the thighs and on to the buttocks. He has usually a very dry skin, excellent diges- tion, is a moderate eater, temperate, hardly smokes, and has his bowels regular The urine analysis shows a marked disturbed ratio urea to uric acid, intense oxaluria, traces of albumen and sugar, some biliary pigments, and traces of indican. He was ordered Pelciba briliantine for the head and Pelciba antiseptic nearly pure on the skin lesions. At the end of about ten days, when he was called away, both the scalp and the groins were nearly well, and later a letter from him says that he was practically cured excepting for some brown stains on the site of the lichenoid eruption. He had continued the treatment by drinking Vittel water at home. A year later reports perfect health. I might continue to cite a large number of other similar examples, or some almost miraculous cures, but these latter are always open to the accusa- tion of post hoc propter hoc. What, however, is interesting is that a not in- considerable number of cases drift here independent of medical advice and 30 often contrary to it, and get better. Another section is formed by those sent by their medical advisers as a last resource in diagnostic and therapeutic despair. In nine-tenths of such cases a sentiment of gratitude and respect is engendered towards their medical advisers, which clinches the tie between patient and physician for the future. CLINICAL HISTORY OF VARIOUS CASES TREATED WITH THE VITTEL WATERS. By Dr. F. Constant of Paris, France. Chronic Rheumatism. H , 38. Father was afflicted with chronic rheumatism, patient a sufferer from eczema, nephritic colics, and chronic rheumatism which began five years ago and involves the knee and ankles. Sedentary habits, no alco- holism. Marked creaking sounds on flexion and extension of the knee. Under increasing, later decreasing, doses of the Grande Source, douches and steam baths, a considerable improvement was obtained. Patient went home, took Vittel water ten days every month. Another course of treatment completed the cure. Chronic Rheumatism. M , 57. Bookkeeper. Sedentary habits, hearty eater. Had had nephretic colics almost regularly once a year for fifteen years, then a free in- terval of four years, followed by new and more violent attacks. Also pains in joints of the lower limbs (slight limping) and in the vertebral column. Fine creaking sounds in left knee, on motion. Pulmonary emphysema. Moderate arteriosclerosis, dilated stomach, highly neurotic temperament. Frequent vertigo. Great excess of water in the urine. Increasing doses of Vittel Grande Source water, warm douches followed by rubbing, or warm bath with massage. After twelve days, patient had reached a consumption of three quarts of Grande Source every morning. Improvement was manifest. The amount was then progressively decreased and, 10 days later, the patient went home. Every month he took Grande Source water for ten days. The winter and next spring passed without nephretic colics, there still was a little gravel in the urine. The pains in the joints had disappeared, barring an occasional twinge. The knee was free from "crepitation" and walking was painless and easy. Chronic Rheumatism and Cystitis. B , 38. Symptoms of cystitis dating back two years, and developed after an operation for inguinal hernia of the bladder. Some frequency of urination and pain on pressure on the hypogastrium. For the past three years, pains in joints. No sedentary habits, hard outdoor life. Fine crepitation on motion of right shoulder. Motion slow and painful. Wrist and finger joints somewhat stiff. No muscular atrophy, but diminished muscular power. Marked crepitation in right knee; no pain. Patient was treated by diet and increasing doses of Vittel Grande Source water, up to 2 l / 2 quarts; then the amount was progressively decreased. To this were added hot douches or baths with massage. The pyuria disappeared and frequency decreased. In three weeks a com- plete recovery was obtained. The articular symptoms were much improved. The right shoulder alone remained painful. Patient was advised to take Vittel water ten days every month. 3i Chronic Rheumatism. Mr. B ,40 years of age, belongs to a family where rheumatism and gout are frequent. Sedentary habits, much intellectual work, practically no physical exercise. Fairly hearty eater. Chronic articular rheumatism for the past 10 or 12 years, particularly af- fecting the knee, shoulder and wrist. Muscular pains, particularly in the nape of the neck. Never had acute articular rheumatism, nor gout, but has two or three sick headaches a month, and besides, is dyspeptic and constipated. Slight arteriosclerosis, heart normal. The liver is hypertrophied and extends half an inch below the costal border. Urine normal except for a slight excess of urates. Under the influence of diet and increasing doses, one to three pints of Grande Source in the morning and a steady dose of Source Salee (about a pint) in the evening, the constipation improved, the hepatic hypertrophy dis- appeared and the joints limbered up. Patient, after going home, took Grande Source water for 10 days every month, and thus could spend a comfortable winter, with but very little of the pain that had been a prominent feature of all previous winters and springs. The occasional twinges of pain, besides- coming at long intervals, were of a very transitory character. Subacute Rheumatism. Muscular Atrophy. G , 51. Sedentary habits, no physical exercise, hearty eater. For the past four or five years has had pains in joints and muscles, then cramps,, tingling or burning sensations in the limbs. Two years ago had an attack of subacute articular rheumatism. Duration three weeks. Four months later, relapse, followed by stiffening of both shoul- der joints, the motion of which is very limited, and cause marked crepitation. The deltoid and all the muscles of the right arm are atrophied. The wasting is still more marked on the left side. "Sand" in the urine. Increasing doses of Grande Source up to 2^4 quarts. Electricity and massage. After one season, the patient goes home much improved. The use of Vittel water and massage was kept up during all the winter. After a second season in Vittel, the cure was complete. COLUMBIA UNIVERSITY This book is due on the date indicated below, or at the expiration of a definite period after the date of borrowing, as provided by the rules of the Library or by special ar- rangement with the Librarian in charge. DATE BORROWED DATE DUE DATE BORROWED DATE DUE C28'63S)M50 RA863.5V83 Lassere The mineral waters of Vittel. L33