私の医学の研究は概ね3期に分けることができる. 第1期は温泉の各種生体機能への作用, つまり生体に対する温泉作用の本態の究明, 温泉の治病機転の解明であり, 第2期は温泉に関係の深い疾患としてリウマチをとり上げ, リウマチに対する温泉作用から出発してリウマチ, 膠原病の臨床的研究へ, そして第3期は温泉を理学療法の一つとして捉え, 理学療法を主な治療手技とするという立場からリハビリテーション医学へのアプローチということになる. 温泉医学, リウマチ膠原病学, そしてリハビリテーション医学, その何れもが当時の医学の領域では日のあたらない未知の分野であり,「見於未萠」の一語に尽きる. いわばその開拓者の役割を果してきたといえる.
本講演では, そのうち私の「温泉の医学的研究」を一つのモデルとして, 私自身の医学における研究の進め方, というより進み方を紹介し,「研究とは何ぞや」について私の考え方を述べ, 若い研究者に捧げたい.

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Questionaire surveys of balneotherapy of rheumatoid arthritis have been put in force for patients with rheumatoid arthritis and rheumatologists. Answers were received in 68% of 600 patients and in 83% of 78 doctors. Forty-three percent of patients have received balneotherapy. Among them, 58% have had doctor's consent before the treatment, and 42% have recognized the efficacy. Half of them have gone to the spa one or two times a year and most of them have taken the bath 1-3 times a day. One fourth of them have experienced the cure reaction. Fifty percent of patients who had not received balneotherapy had no knowledge about this therapy, and 28% of them were disturbed the therapy by their disability. On the other hand, 41% resigned themselves to receive balneotherapy by their economical situation. Eighty-nine percent of patients hope the subspeciality of balneologist in the treatment of rheumatoid arthritis. Ninety-one percent of patients who received balneotherapy answered that they recommended balneotherapy to the other patients by themselves and/or by mutual agreement of doctor. Eighty-eight percent of rheumatologists recommended balneotherapy to their patients, however, 61% of them have done passively. The majority of rheumatologists recognized the need of the facilities for the balneotherapy and 60% of them supported the subspeciality of balneologist in the treatment system of rheumatoid arthritis.

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Criteria for balneotherapy have not been established in rheumatoid arthritis (RA) so far. The body temperature, or erythrocyte sedimentation rate (ESR) is still inconclusive as the standard. We found that urinary hydroxyproline (Hy-pro) may be one of the standards for balneotherapy of RA patient.
1. Urinary hydroxyproline
Daily urinary Hy-pro excretion was significantly higher in RA (41.2±23.3mg/day in 20 cases)
than in control subjects (28.2±14.6mg/day in 22 cases).
In 9 RA patients urinary Hy-pro excretion was decreased significantly after bathing in Konya thermal mud at 42°C for 15-20 minutes, while it increased after the bathing in a systemic lupus erythematosus patient.
On the other hand the urinary Hy-pro excretion was not changed essentially in 5 RA patients who did not take the bathing but rehabilitation exercise as shown below.
Effect of hot spring bathing on urinary Hy-pro excretion
Desease NO Urinary Hy-pro (mg/3hrs)
Before After
RA 9 4.2±2.4 2.1±1.1*
SLE 1 0.4 3.8
RA 5§ 2.1±0.4 2.3±0.4
* p<0.05. § they did rehabilitation exercise only.
From the above results it was concluded that urinary Hy-pro excretion was decreased by the balneotherapy in RA patient, suggesting anti-inflammatory action or stabilizing effect on collagen of the balneotherapy in rhematoid process. On the other hand it was considered that the urinary Hy-pro may serve as a standard for balneotherapy of RA. If it increased after a balneotherapy the patient may have no indication of the therapy.
2. Erythrocyte sedimentation rate
Effect of hot spring therapies on ESR was investigated in 114 RA patients. Improvement of ESR was observed in 30% of RA patients with ESR over 100mm/hr and in the patients with abnormal ESR under 59mm/hr the improvement was found in 31%.
It was concluded, therefore, that ESR is not always a standard for balneotherapy of RA.
3. RA with amyloid nephropathy
Renal function was aggravated after thermal bathing in a RA patient with amyloid nephropathy. Balneotherapy, therefore, must be done very carefully in such patient.

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Commonly, the contra-indication of the balneotherapy to the rheumatoid arthritis are febrile, increased ESR and severe anemic conditions etc. In the Misasa Branch Hospital of Okayama University School of Medicine at 1965-1972, 202 patients with RA were controlled with the Spa treatment. At the first hospitarized time, 39.3% of 150 patients were within 2 years and 16.7% were over 10 years from the onset. And then 43.1% of females and 23.5% of males were febrile over 37.5°C, 46.6% of females and 67.6% of males had positive CRP and 36.2% of females and 61.8% of males had increased ESR over 60mm per hr. So many of the patients were active RA but they had the good control during the balneotherapy. At 52 of re-hospitarized patients, 23.1% were febrile, 32.7% had positive CRP and 26.7% had increased ESR, but samely were good controlled.

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It has been well known that rheumatoid arthritis is an indication to spa therapy. It is real situation that the use of other treatments at the same time makes difficult to assess the effect of spa therapy.
It was thought that knowing the patients opinions for spa therapy and other factors might be a means to evaluate the therapeutic efficacy of various treatments. For this purpose, information by questionaires was gathered from patients. 156 out of 283 patients discharged from this hospital from 1971 to 1975 answered to questionaires. 52 inpatients in this hospital also answered to questionaires.
As regards spa therapy, 57 out of 156 discharged patients (36.5%) visited a spa after discharge and 29 out of 52 inpatients (55.8%) visited a spa prior to admission. Namely, a considerable number of patients has received spa therapy.
Those patients who answered that spa therapy was effective were 35 discharged patients (61.4% of patients visited a spa after discharge) and 14 inpatients (48.2% of patients visited a spa prior to admission). Namely, a conciderable number of patients answered that spa therapy was effective.
As regards spa therapy in this hospital, 36 out of 52 inpatients (69.2%) answered that it was effective and 2 (3.5%) uneffective. 10 patients (19.2%) answered that other spas were uneffective gave answer that spa in this hospital was effective. It is considered that this fact points out that the therapeutic efficacy of spa therapy include factors aside from spa itself.
Further questionaires given to inpatients regarding other factors disclosed that psychological and climatic factors exert considerably influence on improvement of the disease.
The condition of disease was compared the present status with that on discharge. Those patients who had the more advanced stage or class had the more poor prognosis.
Proper medication, physical and psychological rest, good instruction for daily living, proper exercise, and spa bath's were demonstrated to have value for improvement of the disease.
Physical and psychological strain, attach of complication, and discontinuation of drugs were demonstrated to offer worsening of the disease.

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