Georg Ivanovas From Autism to Humanism - systems theory in medicine
Balneology is an empirical method without a concise system. It developed from the search of humans for health, wellness and fun. Thus, it was always associated with all kinds of interests (Marcuse 1903). Vitruv, a Roman constructer shall have said that it is advisable to build temples near natural thermal springs as this increases the fame of the deity (Kisch 1883: 1). But it were mostly economic interests that shaped the business of balneology. People who pay have to be satisfied and supplied with anything. This was true for the religious centres of ancient times. This was true in the middle ages and Renaissance when cutters, cuppers and barbers provided a full service in cutting hairs, extracting teeth and caring for wounds. Baths lasted up to 6 hours with people eating, drinking and having all kind of fun in the bath (Kisch: 4; Marcuse: 76). It was the syphilis that led to the decline and the closure of the baths. Today, in the modern ‘temples of wellness’ the developments are quite similar. Everything is provided from hair cutting to botox injections.
This kind of balneology is more thought to please the customers and is less intended to have therapeutical effects. However, there have always been important medical centres associated with spas committed to a serious medicine. Today it is the association with primary and secondary rehabilitation that gives spas sometimes a high medical standard.
When a more scientific balneology developed by the beginning of the 19th century, the old habitudes were branded, especially the tendency to overdo things (Granichstaedten 1837: 95). New balneology was said to be totally different than the old one (Granichstaedten: 94). The top priority was the understanding of the therapeutic means and their ‘specific’ healing factors (Kisch: 30). Springs were no longer seen as panacea but were connected with certain indications.
A scientific definition, still valid today, was established:
Balneology is an immersion of the body or parts of the body in an airy, liquid, semi liquid or solid milieu (Debay, 1893: 15).
Around 1870 measurements became ever more important. The constituents of the therapeutic means were analysed and quantified, e.g., the minerals of drinking waters, the temperature and the ingredients of baths, as well as the physiological reaction of the body. This new knowledge was compared with the pathological concepts of the time and set in relation to the empirical knowledge (Kisch).
Here an illustration (about 1880) demonstrating the change of the pulse curve after drinking of 300cc water (46o C) showing that it has a greater impact on pulse curve (above) than drinking cold water (below) that left the pulse curve unchanged (Kisch: 29). The opposite had been expected as cold water is said to have a stronger impact on physiology.
But there was (and is) an underlying problem with all these data (actually, it is the practitioner’s paradox). A therapy in a spa is not the use of some defined therapeutic means, but a complex method (Kisch: 25). Sometimes three or more different types of therapy are combined in the regimen. Even in spas with only one therapy, let’s say drinking from a spring, many factors determine the outcome and have to be considered: climate, motion, diet, frequency of drinking. It makes a difference if twice a day a larger quantity has to be drunken or several times a small quantity, whether the spring is in the centre of the spa or in the woods. The right application and combination of the therapeutic means for a given patient depends extremely on the experience of the physician.
The mere analysis of the spring water and the knowledge of its physiological impact gives no hint how to use it. The analysis of the springs of Marienbad (Thilenius 1882: 469) hardly explains the effects of a therapy in Marienbad.
From the ‘specific’ point of view each factor beyond this analysis can be seen as ‘frame’ factors in which the defined therapy (drinking the water) happens. Until the end of the 19th century textbooks on balneology regarded these ‘frame’ conditions as a medical issue. Even the best way to reach the spa, or the clothing were considered (Thilenius 1882). In contrast, current balneological research lays mainly emphasis onto the specific factors. But as the specific intervention is only a part of a wider regimen, modern research is caught in a sort of a dilemma concerning effectiveness and specifity.
In fact, the very distinction between ‘specific’ and ‘unspecific’ becomes doubtful. Taken strictly, everything else than the minerals and the temperature of the springs of Marienbad are placebo effects.
Here are some results of modern balneological research concerned with the question how a certain therapy is specifically effective:
- Baths containing high concentrations of CO2 can be applied in quite low temperatures without the impression of being cold. It can be measured that in CO2 containing baths microcirculation is about double as high, whereas bathing in normal water reduces microcirculation to the half. The results correspond to the subjective feeling of cold, absent in CO2 baths (Karagülle et al 2004).
- Walking on a sandy beach is associated with a high physical strain not seen by walking on firm ground (Stick/Mende 2002).
- Davos has always been an important spa for climate therapy. Its main indication was tuberculosis. Today it changed more to atopic disease (bronchial asthma and neurodermitis). In such patients a decrease of eosinophilic granulocytes and a normalisation of T-cell activation can be seen after 3-4 weeks (Simon/Borelli 2001).
Such results do not create new knowledge, but they quantify well known observations according to certain surrogate parameters. One of these parameters is microcirculation influenced by such different therapies as the administration of warm applications (Berliner et al 2002), electrotherapy (Mucha 2001) or CO2 baths.
However, such parameters do not reflect how the different therapies work, nor is microcirculation able to explain the different impact warm applications, electrotherapy or CO2 baths have. Nor do they enable to compare the therapies. Such parameters are too restricted to represent the whole range of influences a therapeutic stimulus can have on humans. Thez only provide some additional data to empirical knowledge.
Studies might help in doubtful situations. It has been found that warm baths with peloids (Moorsuspensionsbad) with a medium temperature (37o C) induces no further cardiovascular stress and can be applied to patients with a cardiovascular history (Crevenna et al 2003). Such patients had been excluded from this therapy before. That is, the more specific the disease to be treated, the more information provides this kind of research. The rehabilitation and secondary prevention of cardiovascular patients, for example, has improved a lot through balneological therapies (McAlister et al 2001; Stofft et al 2001, Gutenbrunner et al 2002).
This kind of balneological research fits to a medical concept based on specifics: The rehabilitation after a specific disease can be best conceptualised with specific interventions connected with an early detection of pathological changes (Makover/Ebrahim 2005). But this does not mean that it is the best treatment. It only says that in this self-referential circle of therapy and prove no other things are observed by definition. But doing so the epistemological problem does not vanish.
This becomes clearer when the concept of hardening, the attempt to attain robustness, is introduced (chap. 6.6). Actually hardening has long been the main request for balneology. Its benefits have been well known over centuries. It can be attained in many ways and can heal or prevent diseases of all kind. The name of the disease is not important (Granichstaedten: 150). It is a phenomenon of organization. This is why it creates methodological problems on the level of simple measurements.
Of course hardening has physiological effects. It might boost cell mediated Th1 immune reaction and enhance the number of T cells (Kreutzfeldt et al 2003). This is especially true for therapies that induce stress reactions, whereas mainly passive therapies like massage lead only to a temporary reaction (Kreutzfeld/Müller 2001). But this immunological reaction is not specific for hardening. Also amateur choir singing (in contrary to only listening) is able to modulate the immune system and has additional effects, e.g., harmonizing cortisol levels (Kreutz et al 2004). Choir singing has actually a multitude of physiological effects. At the annual Congress for Psychotherapy in Lindau (Lindauer Psychotherapietage) the first session was always music. During one week it was choir singing and during the other week it was listening to music. The difference of mood and feelings was impressive (at least to my not validated observation).
It is somehow difficult or even impossible to define the ‘specific’ effect of choir singing. It has a similar equifinal status as playing (chap. 4.7). Every attempt to nail down one factor leads to somehow doubtful results. Social integration is an important factor in choir singing and social integration improves fibrinogen levels (Loucks et al 2005). Probably nobody would expect that the impact of social communication is sufficiently described in measuring the surrogate parameter of fibrinogen levels. Similarly is laughter an effective remedy (Canisius College 2008), even in chronic disease (Cousins 1985; 1990). But who wants to distinguish the categories of singing, laughing and social communication from each other?
Out of therapeutic reasons it even makes sense to combine such different techniques as bathing, singing and physiotherapy. All these unspecific methods improve health through the same, similar or different pathways. May be the concept of Renaissance has not been as bad after all?
But when different methods are combined it is more difficult to conduct trails, although there have been attempts to do so. Patients with knee osteoarthritis were treated for eight days in a spa hotel. Group I had a thermal water bath and a peloid bath a day, group II had two thermal water baths a day. Both regimens improved significantly function status and pain, however the improvements were significantly higher in group I (Odabaşi 2002). Although this study has many methodological problems, e.g., too few participants and a too short duration, its main problem is not a statistical but a methodological. This study was designed against all principles of balneology, naturopathy or systemic medicine. A stimulus has to be tailored. It has to be adequate for the situation of the patient in regard of his possibilities, resources and interests. To observe this is good for the therapy and for the patients. But it is bad for studies.
The prescription of a regimen does not depend on the knowledge of the physiological effects of the therapeutic means. Contrarily, this is often of minor importance for a balneologist. He has to be experienced, he must have see different courses to understand reactional patterns.
Patients with long standing fatigue might be prescribed a bath of rosemary which has a stimulating effect or a bath of valerian which has a sedative effect. The first is preferred in more depressive states, the second in exhaustion after long standing physical or mental stress. This decision is irrespective of the diagnosis the patient is labelled with. It might be back pain, arthritis, hypertension, Crohn’s disease or something else. The individual has to be understood, not only the conditions of the specific disease. “Individualisation is the main task of a balneologist and of every practitioner” (Kisch: 339).
Empirical knowledge is gained through self-experience. The German education for balneology comprises a lot of self-experience. Only by that the observations in the patient and the reports of the patient can be judged and correlated correctly. Unfortunately many balneological clinics are not run by educated balneologists but by scientists and neither the senior consultant nor the assistants have any personal experience with the therapeutic means they use. However, they contribute to the scientific knowledge of balneology.
The old complaint that doctors make everything wrong as they do not have enough knowledge, give too many remedies in the course of the regimen, leave patients in ‘bad air’, and look more for their own comfort (Anonymous 1837: 53-59) is still partly true today.
Despite the schematic regimen, often prescribed by therapists, there is another sort of individualization in balneology, mostly overlooked. Helpers and physiotherapists in accordance with the patients change often fundamentally the regimen without the knowledge of the doctor in charge. The less the doctor individualizes the higher is the possibility that the actual therapy does not resemble the prescriptions. It takes a very familiar relation with the patient, the physiotherapists and the helpers to be informed what really happens.
All this alters the results of scientific research which depends on surrogate parameters. I suppose that even in drug trials the environment of the patient will strongly influence the outcome of the trail by ‘unspecific’ interventions, particularly, when the results tend to be negative. As balneology is characterized by more ‘unspecific’ factors, this is why this trait is here more prominent.