Balneotherapy

BALNEOTHERAPY (from Latin balneum—bath, and Greek therapeia—treatment). The study of mineral waters, balneology (see), is divided into separate branches, among which balneotherapy, devoted to the questions of the therapeutic use of mineral waters, is of particular importance for practice. The content of balneotherapy consists of the study of the physiological action of mineral waters, methods of their clinical application, and the rules for selecting patients on the basis of established indications and contraindications. Balneotherapists must work in two directions: a) studying and technically preparing the healing powers of mineral springs, lakes, estuaries, and seas, and b) correctly selecting, preparing, and clinically conducting the treatment of appropriate patients. In the first case, balneology helps the balneotherapist correctly evaluate and rationally prepare the use of mineral springs (see Mineral springs); in the second case, a whole series of specific tasks confronts him: 1) establishing an accurate clinical diagnosis for the patient, conducting prolonged clinical observation of him before sending him to a health resort (in a clinical, hospital, or outpatient setting); 2) carrying out (in the order of work of provincial or district selection committees) a strict selection of those patients who can be assigned some other, non-resort treatment, and an especially strict selection of those patients who need to be prescribed balneological treatment at a resort; 3) arranging (in consultation with the attending physician of the selection committee) a thorough, concrete plan of resort treatment, keeping in mind the most beneficial application of the therapeutic resources of the given resort for the given patient; 4) establishing on site (on the basis of this preliminary plan) the final concrete plan of treatment, in accordance with local conditions (usually this is done in a resort outpatient clinic); 5) systematically carrying out this plan at the resort both in the direction of resort-sanatorium regimen and dietary nutrition, and in the direction of balneological procedures; 6) maintaining strictly organized records of treatment results both for further instruction to the given patient and for the elaboration of the scheme of methodology and indications. All this work must be carried out by collective efforts; its success depends on complete coordination between its individual participants. The methodology of balneotherapy comes down to two main forms—external and internal use of mineral water. The study of the physiological action of mineral waters, sea water, and the brine of lakes and estuaries is based on becoming acquainted with their chemical composition, origin, or formation. The physiological action of external balneotherapy (mineral baths and swimming) is based on the corresponding influence of fresh water (see Hydrotherapy). Thermal irritation (cold and heat) and mechanical action (pressure and impact) are preserved in full measure in balneological and marine treatment. But in balneotherapy, chemical irritation by gases (CO₂, H₂S), salts (especially NaCl), and other constituent parts is added to this. Somewhat less substantiated is the influence of radium emanation dissolved in mineral waters. Closest to hydrotherapy is the use of hot chemically indifferent sources (see Acratotherms), which are equated by some with fresh hot baths, while others value them very much for their therapeutic effect, assuming certain physical and chemical peculiarities of hot springs coming from the depths of the earth and mostly connected with volcanic phenomena. Acratotherms are not inferior in their action to fresh hot baths, and therefore are used according to the same indications and contraindications: rheumatism, arthritis of a toxic, infectious, and neuropathic character, myositis, myalgia, neuritis and neuralgia (especially sciatica), organic nervous lesions in the late stages of syphilis (according to a special special scheme of indications with individualization) with coordinated specific treatment, chronic inflammatory processes, especially of a gynecological character, and certain (curable) cases of military and industrial traumatism. The methodology of hot indifferent baths at a resort usually comes down to the following scheme: a) temperature starting from 35°, reaching 40°; b) duration from 8–10 to 15–20 minutes; c) rest and, if necessary, sweating after the bath; d) taking a bath either daily, or with rests, 1–2–3 times a week during a 4–6 week course; e) gradual weaning from hot procedures and from the climate of a thermal resort (deacclimatization); f) subsequent strengthening treatment (Nachkur) with carbon dioxide baths or sea bathing (if there are indications for this); g) repetition of the course the following year, since the chronic course of the disease often does not yield to treatment during the course of a single season. - The influence of chemical constituents is most clearly manifested in gas sources (carbon dioxide and hydrogen sulfide), which partly allow the absorption of gases through the skin, but mainly act as irritants of peripheral nerves and blood vessels, acting in this way ultimately on the nervous and cardiovascular systems and on metabolism. Depending on these physiological prerequisites is the list of indications for treatment with carbon dioxide and hydrogen sulfide baths, in which sluggishly proceeding infectious and toxic arthritis, toxic neuritis, chronic women's diseases, and certain forms of metabolic diseases are usually added to neuroses and cardiovascular diseases. The methodology of carbon dioxide and hydrogen sulfide baths introduces significant corrections to the methodology established for fresh baths: a) temperature is significantly lower than usual, dropping from indifferent (35°) to cool (24°) and more rarely rising from 35° to 37°, which depends on the thermal irritation of nerve endings by gases and entails greater preservation of gas in cold water and, consequently, greater strength of its action; b) duration is shorter compared to fresh and warm baths (from 5–8 to 10–15 minutes!!), since the influence of gases requires stricter dosage, taking into account skin irritation and the inhalation by patients of gases that are poisonous in large doses; c) the duration of the entire course varies greatly, since here it is necessary to pay attention to the patient's condition and the results achieved; d) subsequent treatment is not needed, and the repetition of the course over the course of several coming years is less frequently required; e) compliance with the sanatorium regimen acquires special importance according to the nature of the disease, which is further enhanced by the invigorating action of the baths and some peculiarities of the easily excitable groups of corresponding patients (neurotics). - The chemical irritation from salt baths from salt springs, from the brine of lakes and estuaries, and from sea water is somewhat weaker. Here the action approaches the action of a hot bath, somewhat enhanced and modified by the presence of sodium chloride and other salts. The basis is the thermal influence of the bath, to which is added some irritation from the salts in the bath itself and from the microscopic drying "crust of salt" on the body (according to the Lehmann-Frankenhäuser hypothesis). Occupying an intermediate position between acratotherms and gas baths, salt baths accordingly have indications found in both the first and second groups: rheumatism, arthritis, neuritis, inflammatory infiltrates (especially gynecological), decreased metabolism, and in addition rickets and certain chronic skin manifestations of general body lesions (scrofula). The methodology of warmed salt and brine (more concentrated) baths basically coincides with the methodology of hot indifferent ones. But to this it is necessary to add some additional considerations and rules: a) temperature is prescribed somewhat lower, taking into account the increase in irritation due to chemical parts; b) the duration of the bath and the duration of the course can sometimes change depending on the dosage of the irritant (the saturation of the source water is less than that of lake and estuarine water: from 10–50 g per liter in the former to 100–300 g in the latter); c) gradualness at the beginning and end of the course is achieved by "entry" and "exit" baths, the concentration of which can be changed by dilution with fresh water; d) monitoring the course of treatment requires special attention in individual cases in view of the sometimes encountered increased sensitivity of the skin to salt. As for the methodology of lake, estuarine, and sea bathing, here a significant mechanical influence of the wave impact and the action of the patient's own movements when immersed in water and swimming are added to the general action of the water. In addition, one should bear in mind the especially important influence of the marine and coastal climate, the action of the sea coast both purely physical (the significance of the inhaled air) and the influence of the sea itself on the psyche. Almost all of the listed groups of mineral waters are used to affect the mucous membranes of various directly accessible cavities (mouth, nasopharynx, rectum, vagina). Here there is the same effect of mineral water, enhanced in view of the more delicate cover of mucous membranes and their greater wealth of nerve endings and peripheral vessels. In these cases, gargles, washings, inhalation, douches, irrigations, and enemas are prescribed.

Their technique does not differ from ordinary clinical techniques in the respective special branches, while the temperature and seasonal dosage coincide with ordinary health resort practice. Indications for these local balneological procedures at the present time (over the past decades) are being worked out particularly vigorously, frequently returning to the experience of old balneotherapy and the observations of former physicians. Widely known are throat gargles with alkaline and saline waters, alkaline and saline inhalations for disorders of the upper respiratory tract, nasal cavity irrigations with Matsesta hydrogen sulfide water for chronic rhinitis, vaginal irrigations for gynecological disorders, and deep enemas with Matsesta water for chronic colitis up to its membranous form (colitis membranacea). Balneological treatment in the field of otorhinolaryngology is especially widespread at the hot sulfur Pyrenean health resorts. The forms and methods of external balneotherapy outlined above connect it, on the one hand, with hydrotherapy, and on the other, gradually transition into internal balneotherapy. The internal use of mineral water is especially connected with the study of its chemical composition, since the action of chemical ingredients is most clearly manifested on the mucous membrane of the digestive tract and after the absorption of water into the blood. In assessing the physiological effect of ingested water, balneotherapy is particularly close to pharmacology, since here it is a matter of the balneodynamics of mineral waters alongside the pharmacodynamics of salts and artificial salt and gas solutions. Some scientists equate mineral water when used internally with artificial waters, while others recognize in mineral water a special chemical power unattainable in artificial solutions; the truth should be sought in the middle: in a higher dynamic effect of the very peculiar (physicochemically) fresh mineral water under the combined action of the resort regimen and climate. In any case, the centuries-old experience of balneotherapy confirms the undoubted benefit of drinking mineral water at a resort for metabolic and digestive tract diseases. Even remaining entirely on the basis of the general principles of the pharmacodynamics of salts, acids, and alkalis, one can fully substantiate the effect of drinking water; the observations of balneotherapists in balneological institutes and clinics further strengthen these justifications. In particular, the following details of the physiological action of mineral waters when used internally should be noted: a) gas sources with their CO₂ (and in rare cases H₂S) give the gastric mucosa a strong secretory and motor irritation; b) in the intestine, gases can exert only a very limited effect, since the main mass of gas is either removed by eructation or absorbed in the stomach; c) in the organism, CO₂ after absorption increases metabolic processes; d) alkaline and alkaline-earth waters (see Balneology) with their sodium and calcium ions, as well as bicarbonates and sulfates, cause a response reaction from the mucous membrane of the stomach and duodenum (increasing gastric secretion in the first case and suppressing it by reflex from the duodenum in the second); e) an increase in duodenal secretion, an increase in the alkalinity of duodenal juice, and an increase in bile formation have been noted from mineral waters; f) highly saturated bitter waters, on the one hand, draw water into the intestine from the organism by diffusion and, on the other hand, by irritating the intestinal mucosa, increase intestinal secretion (laxative effect of sulfate waters); g) having been absorbed into the organism, alkaline and alkaline-earth ions undoubtedly take part in the chemical processes of cellular and tissue metabolism, upon which is based their widespread use in gout, obesity, and diabetes (established since ancient times by direct observation of practical balneotherapy and placed at the present time on the agenda for scientific verification. From this follow those extensive indications for drinking mineral waters, which are far from exhausted by the listed examples and which could be supplemented by reference to ferruginous, arsenical, and lithium waters for anemia, gout, alkaline and alkali-salt sources for nephritis, etc. Deep clinical observation of modern balneotherapy and strictly scientific experiments of balneotherapeutic institutes verify the above-listed observations of practical balneotherapy and every day bring them either thorough confirmation or well-thought-out cancellation and replacement. The methodology of internal use of mineral waters comes down to a definite (empirical) dosage: from ¹/₂ to 1-1¹/₂ glasses per intake, 2-3 times a day, predominantly on an empty stomach, half an hour or an hour before dinner (sometimes during meals, as for example, the alkaline-earth sources of Pyatigorsk for hypochylia). The water temperature ranges from natural (10-14-20°) to warmed (25-35°). Hot sources (e.g., the Carlsbad Sprudel at 72.9°) have to be cooled, and very cold ones (e.g., the carbonated sources of Transbaikalia: Yamarovka, Koltomoykon, Darasun at 1-2-3°) warmed in the air; however, local residents often drink the cold sources of Transbaikalia in their natural form, since CO₂ covers the stomach wall with a protective layer of bubbles. Bitter waters—Batalinskaya, Hunyadi Janos, Apenta (see)—are rarely used on the spot and are more often exported for sale. Likewise, the water of many sources with an established reputation for healing is exported in bottles, and in this way resort treatment is translated into purely pharmacy-based treatment (Essentuki, Borjomi, Narzan, Izhevskaya, Vichy, Contrexéville, and many others). The following main ones belong to these groups of mineral medicinal sources: a) acratotherms—Goryachevodsk, Abas-Tuman, Kuldur in the USSR; Plombières, Gastein in Europe; b) carbonated sources—Kislovodsk Narzan, Transbaikal Darasun and Yamarovka; c) hydrogen sulfide and sulfur sources—Matsesta, Talginsky, Pyatigorsk, Psekups, Sergievskoye waters in the USSR, Aachen, Luchon, Piešťany and others in Europe; d) saline sources—Slavyansk, Staraya Russa, Soligalich and many others in the USSR, Wiesbaden, Kissingen and others in Europe; e) salt lakes and estuaries—Elton, Tinaki, Karachi, Shira, Saki, Kuyalnik and Hadzhibey estuaries in Odessa; f) alkaline, alkaline-earth, etc.—Borjomi, Essentuki, Zheleznovodsk, Izhevsky and others in the USSR, Vichy, Contrexéville, Ems, Salzbrunn, Wildungen, Marienbad, Carlsbad in Europe; g) bitter waters—Batalinskaya near Pyatigorsk in the USSR, Apenta, Franz Josef, Hunyadi Janos, Nyitra, Karasna in Europe. - Literature on balneotherapy see Balneology, I. Bagatev.