Whereas, heretofore gout and nephrolithiasis could be discussed from a uniform standpoint, this cannot be done in discussing the use of mineral waters and drugs in these two disorders. For by means of these remedies we aim to achieve perfectly different things in the two diseases.

a - Gout

In the case of gout we must decide whether or not there are means that can counteract the retention of uric acid. One will naturally favor any measure that can produce, however slight, an acceleration of the uric acid elimination. Formerly alkaline waters and alkaline remedies (soda, lithia, magnesia) were very popular, and no doubt alkaline drinking cures often help in gout. Most sufferers from gout, aside from being afflicted with difficulties in the elimination of uric acid and with gouty deposits, also suffer from other disturbances as, for instance, gastric and intestinal dyspepsia of different kind, enlargement of the liver, gallstones, etc., all frequent complications that are favorably influenced by alkaline drinking cures. Hence these patients at the termination of the cure find themselves materially benefited. As far as the uric acid metabolism is concerned such improvement does not, however, become manifest. The idea that the excretion of uric acid can be increased and the body thereby rid of surplus uric acid by alkaline waters cannot be maintained. I merely call attention to the old experience that sufferers from gout are frequently surprised by a typical attack of podagra while they are undergoing a drinking cure in Carlsbad. It appears that this is brought about by a preliminary retention of uric acid resulting from the ingestion of the alkalie. The overloading of the organism with uric acid then precipitates an attack, and this event signals the beginning of the improvement, for during the attack proper the elimination of uric acid increases materially. This interpretation that is borne out by modern clinical and experimental investigations corresponds throughout with the old interpretation given most brilliantly by Sir Alfred Garrod. In healthy individuals suffering from typical gout the disagreeable features accompanying an acute attack need hardly be feared, especially as a long period of well-being is very apt to follow such an attack, and, in fact, further attacks may be definitely prevented thereby. There is no objection, therefore, to ordering an alkaline drinking cure from time to time for patients suffering from typical gout. Carlsbad, Marienbad, Neuenahr, Vichy, etc., will always maintain their old reputation in this regard. On the other hand, I urgently warn against administering small quantities of alkalie permanently to sufferers from gout. All that is accomplished thereby is an interruption of the normal undisturbed elimination of uric acid. For many years I have forbidden my gouty patients the daily use of alkaline table waters (Fachinger, Obersalzbrunnen, Vichy-Celestin, etc.), and I believe that I can justify this interdiction by favorable experiences obtained in actual practice. F. A. Falkenstein decidedly deserves credit for having introduced the hydrochloric acid treatment in typical gout in place of the old alkaline treatment. I emphasize this particularly because I cannot agree with the theoretical basis of Falkenstein's hydrochloric acid treatment of gout. (See my Handbook of the Pathology of Metabolism, Vol. II, page 145; footnote, 1907.) Falkenstein argues that the administration of hydrochloric acid favors the transformation of uric acid to urea and oxalic acid. If this were the case hydrochloric acid would, of course, reduce the elimination of uric acid, but this does not occur. In a gouty subject one is more apt to witness the opposite; namely, an increase in the elimination of uric acid. It is possible that the administration of large quantities of strong hydrochloric acid loosens uric acid from its connections, hence mobolizes it and improves the conditions that favor its elimination. Alkalies, on the other hand, as the above investigations corroborate, act rather unfavorably than otherwise upon the elimination of uric acid in a gouty subject.

Whereas, in typical gout for reasons mentioned above an alkaline drinking cure may occasionally be decided upon, this does not apply to cases of chronic atypical gout (permanent forms of gouty articular disease). In a paper published some 13 years ago I called attention to the fact that empirically better results are obtained from the use of saline mineral waters in atypical gout than from alkaline mineral waters. Experience had shown that the waters of Homburg were especially effective, and so for decades many patients from England sought this resort with good results. In Germany, where practical experience with typical gout is much more limited, the significance of saline mineral waters has not been appreciated to this extent. I find that the opinion that I expressed at that time has since been reinforced by a very much more abundant experience. The first publication on this subject (On the Influence of Weak Salines on Metabolism. Frankfort, 1896. Published by J. Alt) was followed by clinical and experimental investigations reported in full jointly with C. Dapper in my Handbook on the Pathology of Metabolism, Vol. II, page 569, ff. Saline mineral waters, in fact, particularly the waters of Homburg and also the waters of the Rakoczy Spring, in Kissingen, were tested, and all of them showed both in healthy individuals and in sufferers from gout a very striking influence upon the elimination of uric acid. It is possible with the aid of these waters to cause the excretion of astonishing quantities of uric acid. The old empiric doctrine, therefore, coincides fully with the facts elicited by clinical and experimental investigations; although an explanation of the method by which better mobilization of uric acid is brought about is still forthcoming.