The use of Water for the treatment of Kidney Disorders


The treatment of end stage renal failure is always based on the use of water. Both the artificial kidney machine and peritoneal dialysis use a huge amount of water, either in its pure condition (the RDT) or as the main ingredient in PD solutions. As these modalities are rather modern for an article on the history of the topic, we will skip them and proceed to the discussion of more ancient methods, correlating them with more recent times. Recent for us means from the 9th century onwards. The structure of this article was inspired by the Polka dance, originally a Czech dance and a genre of dance and music familiar throughout Europe and the Americas. It is still practiced in many countries and widely in Poland.
In this paper we present extracts from the works of Plato, Hippocrates, Aristophanes, Galen, Pliny the Elder, Paulus Aegineta, Rufus, Alexander, Avicenna with their views on mineral waters in general and their application on renal diseases. Gout and lithiasis figure prominently and were the more prominent indications for that mode of treatment. We followed the evolution of their ideas in time and compared them with the current use of hydrotherapy in various Spas with emphasis on the ones from Central and Eastern Europe.
We conclude that the popularity of hydrotherapy for treating kidney disorders was alternatively increasing and decreasing over centuries, resembling the Back and Forth steps of Polka

Keywords: Hydrotherapy, mineral waters, lithiasis, gout, Galen, Avicenna


The treatment of end stage renal failure is always based on the use of water. Both the artificial kidney machine and peritoneal dialysis use a huge amount of water, either in its pure condition (the RDT) or as the main ingredient in PD solutions. As these modalities are rather modern for an article on the history of the topic, we will skip them and proceed to the discussion of more ancient methods, correlating them with more recent times. Recent for us means from the 9th century onwards. The structure of this article was inspired by the Polka dance, originally a Czech dance and a genre of dance and music familiar throughout Europe and the Americas. It is still practiced in many countries and widely in Poland. Thus, let us consider this structure of the lecture as a tribute to our host country. Polka can be very bouncy and upbeat. Try going Back in the Past and Going Forth in squares, and Front and again. Similarly, we will present various practices and theories about the use of baths for renal ailments back in the past, we will follow their abandonment and then will we witness going forth to their revival.


The article starts the discussion with a general view on the therapeutic properties of baths.

Back in the past:

As the use of water treatments combines mythical, religious, medical and social characteristics, it has been a point of discussion since antiquity. We read in Plato’s Cratylus that: “(…) and should be accepted one name only for the god (Apollo) being the god of music, or arching, oracles and of medicine (…) [as] the same tools are used by doctors and oracles like baths and sprinkling with water, as there is a common goal: A person’s soul and body purification” (1).


Going forth, the revival:

Today, ritual purification through water can be found in the religious ceremonies of Jews, Muslims, Christians, Buddhists, and Hindus. These ceremonies reflect the ancient belief in the healing and purifying properties of water. With time, various qualities of natural waters were considered, or advertised, as beneficial for health.


Back in the past:

Plutarch (1st cent. AD): “Which pain, which abstinence, which drug did solve any disease as quickly as a bath taken timely?” (2) Galen (1st/2nd cent. AD): “When there is an increase of impurities the best purgation is via phlebotomy, then baths and fasting (3) and when these are neglected many ailments appear”. (4) And further on: “Who doesn’t remember his (Kointos’) scorn of warm and cold and dry and wet baths, now he announces names of baths without which no treatment is achieved” (5). Rufus of Ephesus (1st/2nd cent. AD) repeats the above: “(…) if the patients suffer by an abundance of bad humours, they benefit from (…) warm baths (6).

Natural springs had been classified according to their physical properties. Hippocrates had already commented that: “The next worst will be those whose springs are from rocks–for they must be hard–or from earth where there are hot waters, or iron is to be found, or copper, or silver, or gold, or sulphur, or alum, or bitumen, or soda” (7). A more detailed classification was made by Pliny the Elder (1st cent. AD) in his famous Natural History. He himself was a fervent advocate for bathing as his nephew Pliny the Younger states “In the country, the only time he took from his work was for his bath, and by bath I mean his actual immersion, for while he was being rubbed down and dried he had a book read to him or dictated note” (8). Also Paulus Aegineta (7th cent. AD) elaborated on the topic (9). According to Galen, natural waters could also be classified in accordance to their temperature: “The so-called natural springs in some places have a pleasant temperature; in others these are boiling or lukewarm, while the cold ones are everywhere” (4).


Going forth, the revival:

Similarly, nowadays a variety of natural waters is widely advertised as good for health, as we can see from extracts of various pamphlets for spas in Central and Eastern Europe:

  1. The Yeisk resort, on the coast of the Azov Sea, is famous for its healing waters containing hydrogen sulphide (…). The main therapeutic factors of the resort are the unique and rare in the content of iron, mineral waters surpassing in some characteristics all known springs in the world (10).
  2. Carbonaceous: Naturally carbonated waters. Stimulate the appetite and digestion when drunk, increase the digestive secretions of the stomach, pancreas and intestines (11).
  3. Sulphur-containing water reduces gastric secretion, helps digestion, and treats lazy bowels. Less mineralized waters are used for treating calculus (kidney stones) and urinary tract infections (12).
    Apart of the variations of waters, baths and bathing always took place in beautiful scenic landscapes and in buildings with works of art.


Back in the past: 

Romans took this to the extreme, building huge imperial bath complexes full of mosaics, statues, paintings and other luxuries. In many ways, these were similar to community centers. Because the bathing process took so long, conversation was necessary. Many Romans would use the baths as a place to invite their friends to dinner parties, and many politicians would go to the baths to convince fellow Romans to join their causes. The thermae had many attributes in addition to the baths. There were libraries, rooms for poetry readings, and places to buy and eat food. The modern equivalent would be a combination of a library, art gallery, mall, restaurant, gym, and spa (13). Baths were a site for important sculptures; among the well-known pieces recovered from the Baths of Caracalla are the Farnese Bull and Farnese Hercules and the larger-than-life early 3rd century patriotic figures somewhat reminiscent of Soviet Socialist realism works (now in the Museo di Capodimonte, Naples). There were also famous artistic works in the baths of Constantinople (14, 15). Later, Avicenna in his Canon of Medicine in the 10th century elaborated on: The bath-rooms: Temperature of air in different rooms (temperate, warm, hot, and cool); mural decorations (16).


Going forth, the revival:

The use of public baths declined during the Middle Ages, partially revived in the 16th century and reached its peak in the 19th. To limit the search only to France, we quote six novels from Philip Albou’s article on “Taking waters in the French literature” (17). Namely, 1. Michel de Montaigne (1533 – 1592) who compares the particular manners of taking water in France, Germany and Italy in 16th century. 2. Gui Patin (1602 – 1672), the famous Senior of the Faculty of Medicine of Paris, declared to be very perplexed as to the effectiveness of water, going on to declare: “the waters make more cuckolds than they do cure patients!”; 3. The account of Madame de Sévigné (1626 – 1696), from her famous Letters, on taking waters in Vichy in 1676; 4. Thermal treatment (without effect…) of the extinction of voice of Nicolas Boileau (1636 – 1711) at Bourbon-l’Archambault in 1687; 5. The portrait of Irene (alias Madame de Montespan) found in the “Caractères” of Jean de la Buyère’s (1645 – 1696); and finally, 6. An extract of the novel Mont-Oriol by Guy de Maupassant where he evokes the cynical and financial aspects of the creation of a thermal place in the centre of France during the 19th century. The latter, though cynical, explains in part the frenzy of building huge hotels and other buildings in that era to accommodate the well-off’s desire for cure and recreation. Focusing on the subject of this article, we notice an echo of the bath decorations of the past in the modern trend of the last two decades, as more designers and operators recognize the healing benefits of positive distractions, natural views, and daylight within their care environments (18).
Having dealt in brief as an introduction with the general ideas of the benefits of bathing both in the past and in modern times, we will focus now on our central theme that is the use of waters for kidney problems.


Back in the past:

Hippocrates (5th cent. BC): The very cold water minimizes and eliminates the tumours and pain of gouty attacks. (19) He also commented on the impact of the quality of drinking water on stone formation: Men become affected with the stone, and are seized with diseases of the kidneys, strangury, sciatica, and become ruptured, when they drink all sorts of waters, and those from great rivers into which other rivulets run, or from a lake into which many streams of all sorts flow” (5) Galen: For renal diseases you should consume a light diet and very frequent baths. Because drinking too much water is contraindicated in renal disease while purification via the skin is desirable (20). Plutarch refers to the gouty attack of Sulla, the Roman general, who according to Strabo hurried himself to the medicinal waters of the Aedipsos Baths, at the island of Euboea in Central Greece (21). Paul of Aegina (5th cent. AD): “(…) for retention of urine: add a fifth part of heated oil to the water. Such a bath is highly anodyne” (9). Alexander warns on the over-prescription of hot or cold baths for treating renal problems and suggests moderation (22). Hydrotherapy in Byzantium was a strong therapeutic agent for many ailments, including acute nephritis and attacks of gout (23). Avicenna (10th cent. AD): “(…) On the presentations of the urinary stone. Know that when the stone enlarges in the kidney it hinders the urine, causes intolerable pain, and may lead to mental confusion from pain. Each occasion of the pain is called an episode (the pain is intermittent). During the episode of pain the patient should sit in a tub of warm water in which the leaves of cabbage…” (24).

Generally, in antiquity methods for alleviation of pain from kidney stones consisted of (…) baths and warm clysters that were sometimes medicated (25). Hence, even the comic play writer of the 5th cent BC Aristophanes has Dionysus suffer from kidney pains, because of overtiredness, to beg Zeus to permit him to run to the public bath for relief (26).


Going forth, the revival:

In The Principles and Practice of Medicine, William Osler (1849–1919) commented on the topic: “Many patients find benefit from a stay at Saratoga, Bedford, Poland or other mineral springs in this country, or at Vichy or Ems in Europe” (27). In Central and Eastern Europe today, bath treatments for kidney diseases flourish. We present indicatively a few such places:

1) Czech Spas – Treatment of kidney and urinary tract diseases has a long tradition in Marienbad with the use of the god-given effects of natural carbon dioxide. The curative springs, in particular, the hypotonic mineral waters in the drinking cure, are the foundation of therapies for urologic and kidney illnesses in children, adolescents, men and women. Due to the cooperation with the dialysis centre Fresenius in Marienbad, it is possible with advance arrangements, to treat patients requiring a dialysis program (sic!). A fine example of the combination between alternative and high tech treatments based on commercial goals (28).
Czech Spas.

2) The Royal Spa hotel in Mariánské Lázně specialises in kidney and urinary tract treatment. Natural mineral carbon dioxide treatment in the form of both water and dry baths helps the vascular system widen and become more flexible. Carbon dioxide, which is absorbed through the body surface, stimulates receptors of even the tiniest capillaries in our body. It is also suitable for curing cysts, kidney stones and sand (lithiasis) or kidney hypofunction in connection with other chronic diseases (29).

3) In the Carpathian Basin in Central Europe, where Hungary is located, the crust of the earth is very thin, so these waters right from the core of the earth rise to the surface very easily. There are more than 200 thermal spas (…) used to cure kidney diseases. Most Hungarian spa resorts use their hot springs complimentary to regular medicinal methods in many type of diseases and conditions like skin diseases, (…) kidney diseases, neurological problems, etc. depending on the composition of their waters. In Hungary, spa treatments are covered by the Hungarian medical insurance plan and regularly prescribed by Hungarian doctors as part of natural rehabilitation protocols (30).

4) There are more than 1300 mineral sources in Slovakia, used as curative waters for (….) renal diseases. There are 21 thermal spas built on these mineral springs, usually divided in three groups according to type: Balneological spas, Climatic spas, mixed spas. The main focus of the “cure” is often drinking water from the spring (it usually tastes like medicine), but all of the spas listed also offer soothing soaks, medicinal massages!) and other restorative therapies, as well as swimming and other recreational opportunities in beautiful natural settings (31).

5) The oldest balneological centres in Russia are the resorts of Caucasian Mineral Waters. The waters in Zheleznovodsk at Stavropol Krai can heal the digestive system, the pancreas, and kidneys. (11) In the same area, the Mashuk Aqua-Therm hosts the only monument in the world commemorating enemas, unveiled in June 2008 (Figure 1). The 770-pound bronze statue stands nearly five feet tall and was created by a local regional artist named Svetlana Avakova. The use of enemas for treating uraemia has been well established since antiquity.

6) Treatment descriptions – Pühajärve Spa & Holiday Resort (…) for heart diseases, high blood pressure and kidney diseases. The discovery of the mineral springs in 1876 marked the beginning of the history of Rymanow-Zdroj. It specializes in the treatment of children with kidney diseases (32).
The main ways in which baths are useful in treating renal failure were perspiration and toxic substance elimination via the skin, which acted as a kind of dialysis membrane.


Back in the past:

Hippocrates: “We should then abstain from the cathartic methods performed from below (that is, diuretic drugs and enemas). The best of all though is to provoke diuresis and perspiration and get the patient walking” (33).

Aristotle (4th cen. BC): “And soon this (alien substance) is separated and discharged. And the latter when is discharged from below is called urine whereas when it is eliminated through the skin is called perspiration. Both are saline for the same reason” (34).

Rufus: “because it is good for them to be able to perspire if diuresis stops. The best of all is a steam bath in a small vat with the head coming out from the top, so that, while the rest of the body is being heated, one can breathe cool air” (35).


Going forth, the revival:

A Clinical/Historical paper we wrote tried to explain the beneficial role of perspiration in renal failure: “(…) Each human kidney has approximately 1.2 million nephrons. In other words, humans have as many nephrons as sweat-glands (…). The role of the skin as an excretory organ is also demonstrated by the fact that the sweat glands as well as the kidneys have receptors for aldosterone and ADH (…). We found a difference of 16 mg/dl in average blood urea between winter and summer months (mean winter urea 182 mg/dl, mean summer urea 166 mg/dl). These differences were statistically very significant (p<10-27). There was no significant difference in patient body weight between winter and summer months” (36). The following articles back our thesis:

Sauna baths in the treatment of chronic renal failure. 

Snyder D, Merrill JP, Trans Am Soc Artif Intern Organs. 1966; 12:188-92.

Sweating treatment for chronic renal failure. 

Lacher JW, Schrier RW. Nephron. 1978; 21(5): 255-9. “This removal of urea, water and salt suggests that sweating could be used to treat uraemia in conjunction with charcoal hemoperfusion”;

Stimulated sweating in chronic renal failure

Man in ‘t Veld AJ, van Maanen JH, Schicht IM. Br Med J. 1978 Jul 15; 2(6131): 172-3. “With hot baths and/or saunas the urea and creatinine in RDT patient falls”

Hot bath for the treatment of chronic renal failure

Ting Ye, Weiping Tu & Gaosi Xu, Ren Fail. 2014 Feb; 36 (1):126-30: “(…) Therefore, it offers an adjuvant alternative renal replacement method”.

Local application of footbaths for gout has been also suggested.

Back in the past:

Rhazes (9th cent. AD) stated that: “Two factors are involved in gout management via application of water to the feet; the temperature of the water and the time of application. Some patients with gout are advised to use extremely cold water during acute episodes, while others need to apply tepid or hot water (37).

Going forth, the revival:

Claridge in the 19th cent wrote: “A king’s councilor had suffered for six years with the gout (…) repeated cold foot-baths, after some days, caused the inflammation and redness to disappear (38). The method has a modern interpretation: In Foot Bath Therapy, warm water can promote blood circulation, and blood flow after a footbath can increase to 10~18 times above normal, which can improve patient metabolism and Qi-blood circulation. Besides, Foot Bath Therapy can improve the skin functions of mucosa absorption and skin penetration, which can promote the medicine ingredients to be absorbed into the blood (39). Basically, hot therapy is applied when there is no inflammation while cold therapy where there is inflammation/swelling. Contrast Hydrotherapy (CH) has been used for treating and preventing gout besides daily hydration.
The most exotic treatment is via magnetized water. Its ancestor was mesmerism. Practitioners were often known as magnetizers, rather than mesmerists. For about 75 years from its beginnings in 1779, it was an important specialty in medicine, and continued to have some influence for about another 50 years. Hundreds of books were written on the subject between 1766 and 1925. Today it is almost entirely forgotten. Magnetism dressed up as magnetized water, is the new frenzy for treating kidney ailments: In a 19th cent Commentary on Avicenna’s Canon, there is an implication of the impact of the radiation of the soil over the medicinal waters: “His statement contains an important truth. Certain spas and health- resorts (Carlsbad, Bath, Droitwich, Baden, Bourbonne-les-Bams, Is ancy Wiesbaden) owe their virtue not merely to the chemical composition of the water which is taken by the patients, but also to the locality itself. The radiations which pass outwards at those parts of the earth produce a beneficent influence upon them as they walk over the ground” (17). In a more recent article on the efficacy of naturally magnetized water on kidney function, we read: “(…) a daily regimen of 16 ounces of naturally magnetized water was shown to be significant in lowering urine pH, and promoting excretion of acids and toxic mineral salts suggesting an increased ability of the kidneys to remove toxic wastes from the body …” (40). In another similar article: “They had their patients drink bi-polar (treated with both North and South poles) magnetized water. This simple treatment was very effective in breaking up kidney and gall bladder stones into small enough particles to be passed through urine without any pain or danger to the patient (41).



Ancient and medieval practices on the use of water are reincarnated today in the more general urge for alternative, traditional, mythical treatments. They are those who look and make steps Back in the Past  to follow them, there are those who sternly stand for the technological approach turning their back to the past Moving Forwards. Nevertheless, both groups in their contrary movements meet harmoniously in the middle like groups dancing the famous Polka dance Podhale (Figure 2).



  1. Plato (5th cent. BC) Cratylus. In: Burnet J (ed) Platonis opera, vol. 1, 2nd edn. Clarendon Press, Oxford:, 1900, Stephanus page 405, section b, line 2.
  2. Plutarchus (1st/2nd cent AD) Quaestiones Convivales (612c-748d), Stephanus page 662, section C, line 3. Available online at:
  3. Galenus Med. (1st/2nd cent AD) De constitutione artis medicae ad Patrophilum. In: Kühn C (ed) Claudii Galeni Opera Omnia vol. I. Cnobloch, Leipzig, 1821, page 299, line 7.
  4. Galenus Med. De sanitate tuenda libri vi. In: Kühn C (ed) Claudii Galeni Opera Omnia, volume 6, Teubner, Leipzig, 1923, page 244, line 12.
  5. Galenus Med., De methodo medendi libri xiv. In: Kuhn C (ed) Opera Omnia. Volume 10. Cnobloch, Leipsig, 1822, page 467, line 8.
  6. Rufus Med., Quaestiones medicinales, Section 25, line 4 Gärtner H. Rufus von Ephesos: Die Fragen des Arztes an den Kranken. Corpus medicorum Graecorum. Akademie, Verlag, Berlin, 1962.
  7. Hippocrates (5th cent BC) De aere aquis et locis. In : Jones W (ed) Airs, waters places – Perseus Digital Library, section 7, p. 87.
  8. Radic B. (2003) The Letters of the Younger Pliny, Penguin Classics, UK.
  9. Adams Fr. (1844 -47) Paulus Med. Epitomae medicae libri septem. Book 1, Syndenham Society, London, chapter 52, section 1.
  10. About the resort of Zheleznovodsk / Plaza SPA Hotels.
  11. Carbonated (Sparkling) Water: Good or Bad? (2016) Healthline.
  12. Best Water for Kidney Stones – Water benefits health,
  13. Fagan G. (1999). University of Michigan Press, Michigan.
  14. Kaldellis A (2007) Christodoros on the Statues of the Zeuxippos Baths: A New Reading of the Ekphrasis. Greek, Roman, and Byzantine Studies 47 361–383.
  15. Bassett S.G. (1996) Historiae custos: Sculpture and Tradition in the Baths of Zeuxippos. AJA 100: 491– 506 .
  16. Gonzalez C (1929) Avicenna’s Canon Of Medicine. AMS Press, New York. .
  17. Albou Ph. (2005) Taking the waters in the French literature. Book of Abstracts. 3rd Meeting of the ISHM, Patras, Greece.
  18. Di Nardo A. (2015) Healing Masterpiece | HCD Magazine.
  19. Hippocrates (5th cent BC) Aphorisms. Adams Fr (trans) Chapter 5, section 25, line 2.
  20. Galenus Med. De venae sectione adversus Erasistrateos Romae degentes. In : Kühn C (ed) Claudii Galeni. Оpera omnia. Vol. 11. Knobloch, Leipzig, 1826 page 240, line 7.
  21. Plutarchus. Sulla. Perrin, Bernadotte (ed) Harvard University Press, Harvard, 1916. Chapter 26, section 3, line 3.
  22. Alexander Med (6th cent AD) Therapeutics. In: Puschmann T. (ed) Alexander of Tralles, Volume 1, page 481, line 1.
  23. Diamandopoulos A. (1997) Hydrotherapy in Byzantium, Kathimerini Newspapaper June (in Greek).
  24. Ardalan M. et al (2007) Diseases of the kidney in medieval Persia—the Hidayat of Al-Akawayni. Nephrol Dial Transplant, 1.
  25. Touwaide A. et al. (2013) Healing kidney diseases in antiquity. Bios, Cosenza, 115–129.
  26. Aristophanis Ranae (5th cent BC) Ex recensione Guilielmi Dindorfii.
  27. Osler W (1892) The Principles and Practice of Medicine. Republished 1978. Classics of Medicine Library (publ) Birmingham.
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  32. Spa Resorts Russia – Advantour.
  33. Hippocrates. On the Diet of Acute Diseases. In: The Greeks, (1992) Kaktos (pbl), Athens, p. 139.
  34. Aristotle (4th cent BC) Problemata. Bekker I (ed). Gruyter, Berlin,1960, sec 866.
  35. Rufus of Ephesus (1st cent AD) In : Hakkert (ed) De Renum et Vesicae Morbis, Ouevres de Rufus d’Ephese (1963). Amsterdam.
  36. Diamandopoulos A and Goudas P (2000) The substitution of renal function through skin catharsis, a clinicohistorical review. Kidney International 59: 1580 – 1589.
  37. Ashtiyani SnC et al (2012) Rhazes’ Prescriptions in Treatment of Gout. Iran Red Crescent Med J 14(2): 108–112.
  38. Claridge R T (1842) Hydropathy, or the Cold Water Cure. In: Cold Water Gout Cure | Cold Showers, 11 Ιουλ 2012.
  39. Foot Bath Treats Kidney Disease or Kidney Failure – Kidney Disease. Available online at:
  40. Galitzer M and Reminick H (1999) Efficacy of a naturally magnetized water on kidney function. Available online at:
  41. The Health Benefits of Magnetic Water. Publishing web Life-Sources Inc. Available online at:

Water immersion model in nephrology: from hydrotherapy to weightlessness


The term immersion connotes a wide range of different procedures ranging from whole body immersion to head-out water immersion carried out utilizing diverse body postures and water temperatures. Though hydrotherapy has been used for centuries, it was the space program in the sixties of the twentieth century, which gave a new impetus to this procedure as an nonaggressive investigative tool, which has been used in studding the influence of weightlessness on hemodynamic, metabolic, hormonal and nervous system. It was possible because water immersion mimics the weightless state on earth.

During the next years head-out immersion model was used by scientists to investigate function and pathophysiology of cardiovascular system, liver and kidneys. After recognition that water immersion induces diuresis and natriuresis, the procedure has been used to study and to treat the disorders characterized by impaired volume homeostasis, as decompensated liver disease, nephrotic syndrome, essential hypertension, cardiac transplantation, diabetes, primary aldosteronism and pheochromocytoma.

Between investigative groups, which contributed the most in studies with using head-out water immersion model there are teams of M. Epstein (Miami, USA), J.E. Greenleaf (USA), P. Norsk (Denmark), A. Koomans (Utrecht, The Netherlands) and F. Kokot (Katowice, Poland).

Keywords: water immersion, nephrology, hydrotherapy


Hydrotherapy is probably as old as mankind. It is one of the basic methods of treatment widely used in natural medicine, and has also been referred to as water therapy, aquatic therapy, pool therapy and balneotherapy.

Hydrotherapy dates back as far as ancient Egyptian, Greek and Roman times, when Egyptian royalty bathed in oils and Roman bath were frequently visited by its citizens. There is also historical evidence of such therapies having been used in the Far East, e.g. China and Japan – where hot springs were frequently used by people to bathe in. However, in those times people used hydrotherapy exclusively for relaxing and indulging themselves and it was only in the 19th century, that hydrotherapy started to resemble the therapy that it has become in today’s society. Heinrich Friedrich Francke (1766-1838), Vincent Priessnitz (1799-1851) and Sebastian Kneipp are supposed to be the pioneers of hydrotherapy.


Water immersion as a type of hydrotherapy

Nowadays hydrotherapy procedures can be divided to:

  1. Surface hydrotherapy with absorbent materials (e.g. washes, friction rubs, wraps packs and compresses);
  2. Hydrotherapy showers with variations in water striking pressure (douches, showers);
  3. Procedures based on the effects of hydrostatic pressures (under massage, whirlpool bath, exercise in water, full and partial immersion bath).

Among partial immersion modalities, head-out water immersion is of particular importance. Its effect on different body organs depends on water temperature. Therefore immersion in water at temperature e.g. 14, 20 and > 360C is commonly referred to as thermotherapy.

In the next part of the paper the head-out water immersion in neutral bath, ie. at temperature approximately 32-360C will be discussed and referred to as WI.


Differences between WI and saline administration

The most important effects of WI in humans are (1):

  • prompt redistribution of circulating blood from the periphery to the heart and great vessels of the chest and the neck, especially in the areas with volume-, baro- and chemo- receptors with a relative central hypervolemia,
  • increase in cardiac output by 25-33% and central blood volume by ~ 700 ml,
  • progressive diuresis and natriuresis equally in magnitude to those induced by acute NaCl administration (2 l/2 h).

Despite of many similarities, there are some significant differences between WI and saline administration (1).

  1. WI is associated with decrease in body weight rather than the increase that occurs after saline infusion.
  2. Majority of studies have indicated that systematic blood pressure is unaltered during immersion in normotensive studies and can decrease in patients with hypertension. Saline infusion always causes increase in blood pressure.
  3. WI doesn’t cause any changes in plasma compositions, while saline infusion does.
  4. WI entails a central hypervolemia without concomitant peripheral hypervolemia, whereas saline administration involves both a central and peripheral hypervolemia (in majority of studies).
  5. And, what is also important, action of WI is promptly reversible, while saline infusion doesn’t.


Head out WI as an investigative tool

Thought many from mentioned facts were already acknowledged in the second half of the 19th century but, unfortunately, there were no practical implications until about 100 years later. There are two applications of water immersion: as an investigative tool and as a therapeutic maneuver. Both applications and based on the above mentioned redistribution of blood volume.

Research studies of Henry Gauer et al carried out in the 50s and 60s 20th century are considered the true beginning of water immersion as an investigative tool. It is ironic that the recent widespread interest in WI as an investigative tool received its impetus not from centuries of hydrotherapeutic practice but from the modern space program. It turned out that, due to the buoyant property of water, head-out water immersion mimics the weightless state. It has therefore been used in studying the influence of weightlessness on human body (2). Norsk et al emphasized the similarities between these two conditions with respect to renal excretion of sodium and water (3).

The number of research studies significantly increased in the 70s and 80s of 20 century, including studies on the effects of WI on renal function. Table 1 presents the number of papers listed in Pub Med that had been prepared by each of the mentioned research teams. All these papers discussed WI as an investigative tool.

In his excellent review Murray Epstein described the mechanisms by which head-out water immersion causes increase in urinary sodium excretion and therefore increase diuresis and decrease blood pressure. The main mechanisms are: inhibition of RAA system, increase of renal prostaglandins production and increase of natriuretic peptides (3).

He also proved, that the rise in urinary sodium excretion occurred no matter how big was sodium contents in diet. On the 10 mmol sodium excretion were of course smaller, than on the 150 mmol, but in compare to controls, in bath cases increase was significantly higher. This increase in urinary sodium excretion decreased after giving steroid, but was still significantly higher than in controls.

In healthy subjects WI induced enhanced diuresis and natriuresis at last partly by suppression of the RAA system, vasopressin secretion, the pituitary adrenal axis and by enhanced of natriuretic factors (4).

In hypertensive patients WI induced a significant decline in plasma renin activity, aldosteron and AVP which is quantitatively different from that observed in normals. As WI induced reduction of blood pressure was not significantly related to endocrine alterations, it seems, that factors other than PRA, Aldo and AVP are of importance in the maintenance of the particular types of hypertension (5).

In contrast to non-pregnant women, healthy pregnant women and women with EPH gestosis showed a significantly reduced increase in ANP secretion induced by WI (6). In diabetes type 1 and type 2 WI induced ANP secretion was significantly reduced as compared with normals. Despite a reduced response of ANP Secretion, the WI induced enhanced diuresis was a comparable magnitude both in normals and diabetics (7). In heart transplant patients ANP plasma levels were significantly higher than in normals  and heart transplant patients. These results suggest presence of an infect physiological regulatory mechanism of ANP secretion in heart transplant patients (8).

To summarize the outcomes of the Kokot group, it can be concluded, that the importance of ANP secretion in the WI induced increase of diuresis may vary in different pathological states. However, first of all WI may be used as an nonaggressive investigative tool in patients with disturbances of the water electrolyte homeostasis, supplying information of endocrine organs, kidneys or nervous system in their pathogenesis.

Research studies into the WI model have been continued in the 21st century. Schou et al demonstrated, that suppression of generation of angiotensin 2 plays an important role in the natriuresis during WI (10). Valenti et al found that WI is associated with a reversible increase in urinary aquaporin 2 excretion (11). Recently Wang et al investigated the influence of WI on human motions and demonstrated that both the wrist and trunk activities were significantly decreased (12).


WI as a therapeutic maneuver

As mentioned before, WI was also used as a therapeutic maneuver in patients with excessive sodium and water retention.

The research has revealed the efficacy of WI as a therapeutic intervention for the variety of disease including essential hypertension (48 items in Pub Med), nephritic syndrome (9 items in Pub Med), decompensated liver cirrhosis (4 items in Pub Med), preeclampsia (7 items in Pub Med) and heart failure (38 items in Pub Med).



Presented in the article facts let to conclude, that WI was of great importance in development of nephrology as an investigative tool and therapeutic maneuver.


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