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Chapter 40 Hydrotherapy*

image Introduction

Hydrotherapy may be defined as the use of water, in any of its forms, for the maintenance of health or the treatment of disease. It is a cornerstone of naturopathic therapeutics, drawing on the vitalistic roots of the nature cure tradition as it stimulates the body’s inherent self-healing mechanisms. The power of hydrotherapy is demonstrated by the persistence of its use now, two centuries after it was first systematized as a therapeutic modality in Western medicine. Naturopathic colleges and universities universally teach hydrotherapy as a core therapeutic modality and utilize it in their teaching clinics on general medicine, physical medicine, and specialized hydrotherapy shifts. Practicing naturopathic physicians utilize hydrotherapy widely in their practices, with some notable doctors, such as Cathy Rogers, ND; Nancy Welliver, ND; and Letitia Dick-Kronenberg, ND; having long-standing practices that emphasize hydrotherapy as their primary therapeutic modality. Additionally, many students at the various naturopathic colleges and universities seek preceptorships and supplementary education specific to hydrotherapy, as well as organizing campus clubs designed to give students greater exposure to and experience with this powerful medicine.

In his original chapter in the first edition of the Textbook of Naturopathic Medicine, Dr. Barry wrote: “Although one of the oldest known therapies, it [hydrotherapy] has received little attention from the research community, particularly recently. Much of the information presented here is compiled from older works which, although they lack the quantification available with current technology, show a remarkable attention to clinical effects and patient response.” What these older works tell us about the uses and effects of hydrotherapy and the specific details of the means employed is invaluable, and physicians practicing hydrotherapy will find its greatest effectiveness by mining the wisdom of the original practitioners of Western hydrotherapy. For example, the individualization of a particular treatment to suit the vitality, or lack thereof, in each patient, must be attended to for treatments to have their greatest impact. It is this need for individualization that, like other aspects of holistic medicine, confounds the conducting of modern hydrotherapy research. However, in the last few years, attention has increased around the topic of hydrotherapy research and practice.

image History

As one of the ancient methods of treatment, hydrotherapy has been used to treat disease and injury by many different peoples, including the Egyptians, Assyrians, Persians, Greeks, Hebrews, Hindus, and Chinese. For example, in the Riga Veda, circa 1500 BC, we read that “water cures the fever’s glow.”

Hippocrates used hydrotherapy extensively around 400 BC, and his writings concerning baths contain some of the earliest dictums on the therapeutic uses of water1:

As these early writings show, the healing effects of water were observed and used therapeutically for centuries before the modern hydrotherapy movement. Modern hydrotherapy has had many contributors, including Sir John Floyer, William Winternitz, Johann Schroth, Johann Hahn, and J.H. Rausse to name a few.

Naturopathy grew out of the hydrotherapy movement, which traces its roots to two prominent hydrotherapists: Vincent Priessnitz of Austria and Father Sebastian Kneipp of Bavaria. Neither had formal medical training, but learned their craft through personal experience and astute observation. Priessnitz observed wounded animals bathing in cold water and was inspired to heal his own broken ribs using cold compresses. Father Kneipp healed his tuberculosis after reading Johann Hahn’s Lectures on the Wonderful Healing Power of Fresh Water.

Priessnitz opened his first hydrotherapy institution at Grafenburg in 1826 and successfully treated over 40,000 people with little loss of life. Many of his patients were very ill and unable to be helped by medical doctors. He was arrested many times for practicing medicine without adequate training but eventually was given all the privileges of a medical doctor because his treatments were so effective.

Father Kneipp became an ordained priest in 1852 and was assigned as a chaplain to a number of parishes. He began using the water cure to treat his parishioners who were unable to be helped by medical doctors. Although church leaders did not approve of his practices and forbade him continuing, still he continued. He was transferred to Worishofen, where his successes became known, and people came from near and far to receive the cure. He never charged for his services, believing care should be available to anyone in need. His first book, My Water Cure, was written for the common people in clear and plain language and is an excellent instructional manual for anyone interested in hydrotherapy today.

Priessnitz’s philosophy of water cure was brought to the United States in the mid-nineteenth century. Joel Shew, a medical doctor from New York, studied with Priessnitz and returned to the United States to start a hydropathy institute based on his teachings. An associate of Shew’s, Russell Trall, MD, started his own hydrotherapy institute in Manhattan in the 1850s and later published the Hydropathic Encyclopedia. John Harvey Kellogg attended Trall’s institute, and in 1900 published Rational Hydrotherapy,2 in which he considered the physiologic and therapeutic effects of water, along with an extensive discussion of hydrotherapeutic techniques.

There were other notable individuals who were influenced by Priessnitz’s water cure philosophy. Robert and William Wesselhoeft studied with Priessnitz and opened a sanitarium in Vermont after immigrating to the United States from Germany. David Ruggles, a black abolitionist who was treated by the Wesselhoefts, opened his own clinic; his patrons included fellow abolitionists Sojourner Truth and William Lloyd Garrison. Mary Gove Nichols, a woman denied any formal education but with a keen interest in medical science and determination to learn, opened her own institute in New York in 1845. She studied with both the Wesselhoefts and Joel Shew.

Benedict Lust, considered to be the father of naturopathy, was successfully treated by Father Kneipp and was charged with introducing the water cure to the United States. Lust successfully combined water cure with other nature cure modalities, establishing the foundation of naturopathic medicine. Henry Lindlahr, a wealthy U.S. banker suffering from diabetes, visited Kneipp after being told by his physicians that there was nothing they could do for him. He was put on a strict diet and daily regimen of cold water treatments. Once cured, he returned to the United States, completed medical training and opened a sanitarium in Chicago in 1906. He believed the vis medicatrix naturae was the true physician and wrote Nature Cure,3 the definitive guide to the philosophy and practice of nature cure medicine.

Otis G. Carroll, one of the modern forefathers of naturopathic medicine, studied with Lindlahr and Alex Ledoux, another student of Sebastian Kneipp. He pioneered constitutional hydrotherapy, the combining of compresses with electrical stimulation, believing this therapy changed the constitution of the body’s cells. Carroll’s work was continued by Harold Dick, a naturopath in Spokane, Washington. His daughter, Letitia Dick-Kronenberg, worked with her father after completing her studies at the National College of Naturopathic Medicine and continues to practice and teach the hydrotherapy practices passed on to her.

Hydrotherapy has a long, rich history, and naturopathy is rooted in its practice. Thus, it is still taught in naturopathic educational institutions and practiced in their associated teaching clinics as a highly effective, fundamental naturopathic modality.

image Physiologic Effects of Water

The physiologic effects of hydrotherapy may be classified as thermal, mechanical, and chemical. Thermal effects are produced by the application of water at temperatures above or below body temperature. The greater the variation from body temperature, the greater the effect produced, other factors being equal and allowing for individual patient variability. Mechanical effects are produced by the impact of water acting on the body surface in the form of sprays, douches, frictions, immersions, whirlpools, etc. Chemical effects are produced when water is taken by mouth or used to irrigate a body cavity, such as the large colon. Thermal effects are the most commonly used therapeutically and are, thus, the main subject of this chapter.

In general, hot relaxes and sedates, whereas cold stimulates, invigorates, and tonifies. However, very hot can stimulate and also be destructive, whereas prolonged cold can be depressive and destructive. A comparison of the effects of hot and cold on several body systems is given in Table 40-1.

Principles of Blood Movement with Hydrotherapy

To promote healing, either locally or systemically, it is important to maximize circulation of well-oxygenated, nutrient-rich blood, which also has the effect of carrying away metabolic and other waste products. Hydrotherapy techniques are one of the most effective means of accomplishing this, especially when used in conjunction with proper levels of activity, optimal nutritional intake, and adequate detoxification.

Using different temperatures of water, one can either increase or decrease the rate of blood flow (BF) through an organ or area of the body and can either increase or decrease the total volume of blood in an organ or area of the body, according to whether the area is anemic or congested. To accomplish these changes, five relevant physiologic principles must be considered:

Revulsive Effect

The revulsive effect provides a means of increasing the rate of BF through an organ or area of the body and is most effectively accomplished using contrast hydrotherapy: alternating hot and cold in the form of compresses, baths, showers, sprays, etc. Local contrast applications produce marked stimulation of local circulation. A 30-minute local contrast bath produces a 95% increase in local BF when the lower extremities alone are immersed. When all four extremities are immersed at the same time, there is a 100% increase in BF in the upper extremities and a 70% increase in the lower extremities.4

Contrast applications to the area of skin that is in a reflex relationship (see Spinal Reflex Effect, following) to an organ increase the functional activity of that organ. Hence, liver function is increased by contrast application over the right upper quadrant of the abdomen.

Several studies have researched the optimal treatment times for revulsive effects. Woodmansey et al5 found 6 minutes of hot application and 4 minutes of cold to be optimal for the British subjects he studied. Krussen6 found 4 minutes of hot and 1 minute of cold to be the best treatment protocol. Moor7 stated that 3 minutes of hot followed by 30 to 60 seconds of cold provided satisfactory clinical results. These variations create an inference that, due to variations in patients and locales, it is best for practitioners to determine their own ideals, based on their own observations of clinical results. Most importantly, the cold application needs to be long enough to produce vasoconstriction, which can occur in as short a period as 20 seconds. Additionally, the course of treatment should always end on cold to discourage congestion in the area.

Repetition of applications is another important variable to consider when applying revulsive treatments. A series of three hot/cold applications seems to be practical. Most individuals show a decreasing reaction to repeated applications of cold.

The revulsive effect is ideal for treating situations presenting primarily as congestion, for example, the use of alternating hot/cold compresses over the face for sinus congestion. As a powerful decongestant, the revulsive effect also acts as an analgesic for pain resulting from congestion. Because of its marked stimulation of local circulation, the revulsive treatment is an exceptionally effective hydrotherapeutic procedure, and one of the most generally useful considering its simplicity.

Spinal Reflex Effect

A sufficiently intense local application of hot or cold not only affects the immediate skin area but also causes remote physiologic changes, mediated through spinal reflex arcs (see Moor7), thus providing a means of affecting a distant area of the body through a local application. These effects have been carefully observed over many years and have led to a mapping that correlates each surface area with a corresponding internal area and/or organ. Most texts on hydrotherapy contain such a diagram.2,7

Hewlett,8 Stewart,9 and Briscoe10 all noted changes in BF in the opposite arm and hand when one arm and hand were placed in hot or cold water. Poulton11 demonstrated that esophageal function could be influenced by irritation of the skin over the sternum. Bing and Tobiassen12 showed reflex relationships between the skin of the abdominal wall and the colon. They also demonstrated a reflex relationship between the lungs and the skin of the chest wall.

Fisher and Solomon13 stated: “externally applied heat not only decreases intestinal blood flow, but also diminishes intestinal motility and decreases acid secretion in the stomach, while cold has the opposite effect.” This is an example of a contrary effect, in which the reflex effect is the opposite of that observed in the local reflex skin area (i.e., local heat increases BF to the local skin, but decreases BF to the reflex organs).

Tables 40-2 to 40-4 show some of the observed reflex effects of hydrotherapeutic procedures.7

TABLE 40-2 Reflex Effects of Prolonged Heat

One extremity Vasodilation in contralateral extremity
Abdominal wall Decreased intestinal blood flow, intestinal motility, and acid secretion
Pelvis Relaxes pelvic muscles, dilates blood vessels, and increases menstrual flow
Precordium Increases heart rate, decreases its force, and lowers blood pressure
Chest Promotes ease of respiration and expectoration
Trunk Relaxes ureters or bile ducts and relieves renal or gallbladder colic
Over kidney Increases production of urine

TABLE 40-3 Reflex Effects of Prolonged Cold

Trunk of an artery Contraction of the artery and its branches
Nose, back of neck Contraction of the blood vessels of the feet and hands and nasal mucosa
Precordium (ice bag) Slows the heart rate and increases its stroke volume
Abdomen Increases intestinal blood flow, intestinal motility, and acid secretion
Pelvic area Stimulates muscles of the pelvic organs
Thyroid gland Contracts its blood vessels and decreases its function
Hands and scalp Contraction of brain–blood vessels
Acutely inflamed areas Vasoconstriction and relief of painful joints or bursae

TABLE 40-4 Reflex Effects of Short Cold

Local application of intense cold as brief as 30 s General peripheral vasoconstriction
Face, hands, and head Increase in mental alertness and activity
Precordial area Increase in heart rate and stroke volume
Chest, with friction or percussion Initial increase in respiratory rate, then slower, deeper respiration

Arterial Trunk Reflex

The arterial trunk reflex effect is a special case of the general reflex effect.2 Prolonged cold applied over the trunk of an artery produces contraction of the artery and its branches distal to the application. Prolonged hot applications have the opposite effect, producing dilatation in the distal arterial bed. For example, prolonged cold application over the femoral artery in the groin will decrease BF in a foot or ankle with an acute injury involving either internal or external hemorrhage. After the acute phase, prolonged hot applications can be used to increase circulation and speed healing of the injured part.

Local and Systemic Effects of Cold Applications

Local cold applications produce vasoconstriction in the local tissues, leading to a decrease in local circulation. If the cold application is long, intense, and covering a large enough area, a slowing of the general circulation may occur. The migration of leukocytes and inflammatory agents from the vascular system into the local tissues and local metabolic activity are decreased, leading to a more moderated healing response to acute injury. Nerve conduction velocities are diminished, resulting in decreased sensation, including pain, as well as slowed motor response. Muscle tissue tends to contract, and connective tissues become less plastic. Thus, cold applications may assist in the tonification of muscle tissue, leading to benefits such as increased urinary sphincter tone. General applications of cold are hypothermic and produce a peripheral vasoconstriction with shunting of the blood to the core.

Water temperatures below 50°F are considered very cold and may be depleting to many patients if used generally, although ice packs can be an effective local treatment for swelling and pain. Temperatures between 50°F and 70°F are considered cold and are often the more desired range for many cold water treatments.

Cold applications are often prescribed for the relief of pain. Saeki5 found cold, but not hot, applications to be useful in the relief of prickly pain sensations experimentally induced in study subjects. Pain sensations were measured on the visual analog scale, and skin BF and skin conductance levels (SCL) were also measured. Cold applications decreased pain, BF, and SCL, whereas hot applications increased pain, BF, and SCL.

In 2002, a small (19 patients) study entitled “To Evaluate the Effect of Local Application of Ice on Duration and Severity of Acute Gouty Arthritis” was published.14

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