Therapeutic Bathing in Rabbinic Literature: Halachic Issues and their Background in History and Realia
Avraham Ofir Shemesh
Therapeutic bathing has been in vogue since antiquity. In the course of the generations, the therapeutic characteristics of various springs, lakes, and other mineral waters have been established, leading to their use in a variety of diseases. General historical sources, just like Jewish sources from the Talmudic and post-Talmudic periods, mention the use of therapeutic springs and baths in various locations.
This article discusses the halachic aspects of therapeutic bathing and is based on Jewish, halachic literary sources. The purpose of this study is to present the therapies which were used in terms of the halachic problems which they engendered. In this article, we will not endeavor to reach and definitive halachic conclusions in controversial areas. Rather, we will focus on the medical and halachic issues which arose in connection with these therapies.
1. The Therapeutic Characteristics of Baths: Medical and Historical Background
Therapeutic springs are a geo-hydrological phenomenon arising from the leaching of minerals from the earth as hot water rises under pressure from the water table. Various expressions are used for such waters: hot springs, mineral water, and thermal water. In Hebrew, they are called hammot; in Arabic: ma’ sukhna.
Thermal water rises from deep in the earth and contains foul smelling sulfuric gasses as well as other minerals, such as potassium, calcium, sodium, chlorine, and magnesium cations and chlorine anions, silicon dioxide, sulfates, and more.
Thermal waters are to be found primarily around geological faults.. Each spring has its own characteristic minerals, derived from the surrounding conditions and the specific rock formations in the area. It follows that each spring has distinct therapeutic properties for various diseases.
Thermal springs are located in various places. We shall briefly survey the situation in the area surrounding the Dead Sea. Along the geographic fault running through Israel, from the Jordan Valley to the Dead Sea, there are a number of well-known therapeutic springs. Among them are the hot springs of Tiberias and a series of springs on the south shore of the Dead Sea (Hammei Zohar, Ein Boqeq, and Hammei Mazor). The water in these springs is quite hot and the mineral level is rather high. The water is also relatively radioactive.
This phenomenon is usually explained by the fact that water with high salt content is trapped underground. As the water rises to the surface, it passes through stone-age strata containing phosphates and bituminous shale. By leaching out the radioactive substances which accompany the phosphates and the sulfuric compounds in the bituminous shale, the water acquires a certain level of radioactivity and hydrogen sulfide (H2S).
In Talmudic literature, the usual expression for therapeutic springs is hammei teverya or mei teverya. It should be noted that these expressions are not limited to springs in the vicinity of Tiberias. Rather, the “Tiberian Springs” became the generic expression for all hot springs everywhere in the world.
Use of such springs included bathing, drinking, and mud baths A number of sources scattered through Talmudic and contemporary non-Jewish sources indicate that the spring waters were used to cleanse the stomach, deal with general weakness, nervous diseases, and a variety of skin problems such as leprosy and boils.
Each spring in Israel was known for its ability to cure certain diseases For example, the springs of Kalliroë were thought to be effective for skin diseases, irregularities in digestion, and rheumatism. The Ba’ara Springs were good for every condition, but especially nervous diseases The Pahal Springs were used for skin disorders; the Emaus Springs for nervous conditions, sexual problems and lesions caused by wild animals.
Hot springs remained popular for therapeutic purposes through the Middle Ages into modern times. Post-Talmudic halachic literature of Eastern European origin documents the popularity of European spas, frequented by Jews from East to West for therapy, health, and convalescence.
Among the springs mentioned in responsa are: Tiplitz, Ovin, Carlsbad, Barcelona. To this very day these sites are used therapeutically. Recent studies in Israel and abroad lend scientific support to the contention that bathing in such hot springs is medically effective for skin conditions, routine lesions, nervous disorders, and other problems. Even drinking the water has been found to be effective.
New theories, such as hydrotherapy, balneotherapy, and radiotherapy, have been developed to explain the therapeutic effect of hot springs.
2. Therapeutic Bathing in Talmudic and post-Talmudic Literature
In Talmudic, medieval, and modern rabbinic literature there is a series of questions which arise in connection with the use of hot springs. For example, heating water or food on Shabbat; koshering of utensils; ritual immersion, ritual washing of the hands; etc.
In this article, we shall focus exclusively on medical issues. It is interesting to note that there are relatively many references to hot springs in the halachic discussions of the Mishna and Talmud. It seems reasonable to conclude that there are two elements in the historical and halachic background for this: (a) the increased size of Jewish settlements in the vicinity of the hot springs in the mishnaic and Talmudic periods; and (b) the arrival of local Jewish sages to undergo therapy at the spas. Not only the sages went to the spas; Jewish residents from various areas in Israel and the surrounding areas also went.
The differences and unique characteristics of each spring gave rise to questions and practical halachic problems for those who went there. In addition, the therapeutic springs also provided intellectual-halachic stimulation for discussions in the academies in the context of discussions of more unusual situations. In such discussions, medical issues were particularly prominent.
I. Drinking Mineral Water for Therapeutic Purposes (Mei Teverya, Mei Deqalim, Mei Deqarim)
Therapeutic spring water was used for internal problems, such as cleansing the stomach and treating digestive problems. Both the Palestinian and Babylonian Talmuds explained that such purgative water was called mei deqalim or mei deqarim after its point of geographic origin or after its therapeutic effect.
The Palestinian Talmud describes such water as follows: Mei deqarim pierces the gall bladder… Mei deqalim goes out from between two date palms.
The Babylonian Talmud has a more precise tradition (Shabbat 110a):
Those who say “mei deqarim” refer to the piercing of the gall bladder; those who say “mei deqalim” refer to the water which goes out from between two date palms. What is “mei deqalim”? Rabba bar Barona said: There are two kinds of palms in the west [of Israel] and a spring of water goes out from between them. The first cup loosens; the second causes diarrhea; and the third passes out just as it enters.
According to the Palestinian Talmud, the phrase mei deqalim refers to a spring which goes out from between to date palms. Prof. Zev Vilnai suggested that this refers to springs in the area of the Dead Sea where there were many date palms in the Roman period. It is probable that they were referring to water derived from the springs of Kalliroë (Kalliroë in Greek means “beautiful flow”). These springs are on the eastern shore of the Dead Sea.
It is interesting to note that these springs, surrounded by therapeutic baths, were marked on the Midba map (from the sixth century) between two date palms, just as the Talmudic sages described them.
Suessmann Munter, a historian of Jewish medicine, suggested that mei deqalim is tamarhindi, derived from the tamarindus indica plant. Support for his suggestion can be found in the fact that the sages mentioned dates as causing diarrhea just like me deqalim (Ketubbot 10b).
The suggestion is nonetheless dubious because the date palm usually mentioned in Talmudic literature is the common date palm (phoenix dactylifera).
The Babylonian Talmud refers to two additional medical facts in connection with mineral water: (a) it pierces the gall bladder. It seems that because of its high concentration of minerals, it was called mei deqarim (i.e., “water which pierces);
and (b) that it was used to cleanse the stomach and prevent constipation. One cup loosens the stomach and softens it; a second cup causes diarrhea; and a third cup comes out directly from the anus. This implies that such water lead to very acute diarrhea In other words, mei deqalim is a strong purgative which must be used cautiously and in relatively small doses.
Drinking Mineral Water: Halachic Aspects
In ancient as well as in modern halachic literature, there are a number of contexts in which drinking spring water is discussed:
A. Laws of Ritual Purity
The Mishna (Makhshirin 6:7) discusses the halachic ramifications of drinking mineral water on the preparation of the liquids in becoming liable to become ritually impure:
The following neither render impure nor prepare fruits for becoming impure: …Drinking the waters of Tiberias although they be clean when excreted.
The point of the Mishna is that even after drinking the waters of Tiberias, they are still clean and resemble regular water when excreted from the body. Nonethless, their halachic status is not that of regular water which does indeed prepare fruits for becoming impure.
This source indicates that they drank foul water containing various minerals believing that those minerals were healthful.
B. Drinking Spring Water on Shabbat
The Mishna (Shabbat 14:3) discusses various prohibited therapeutic activities on Shabbat. Among them is the drinking of mineral water:
Any food that a person eats for therapeutic purposes and any drink aside from mei deqalim and a cup of roots [are prohibited on Shabbat] because they cure jaundice. But it is permitted to drink mei deqalim for thirst and it is permitted to anoint oneself with the oil of roots for non-therapeutic purposes.
The Mishna clearly considers mineral water to be therapeutic. Therefore, it is prohibited on Shabbat. If, however, a person drinks it for thirst and his purpose is only to quench his thirst, it is permitted. It must be assumed that such mineral water was in general not drunk. They would drink it only in the absence of any other beverage or for therapeutic purposes.
There is a parallel discussion of drinking mineral water in the Tosefta (Shabbat, ed. Lieberman, 12:13):
One may drink ichor, mei deqalim, or a cup of roots. One rinses the face, hands, and feet with them. But one may not rinse a sandal with them. Rabbi Yohanan the Sandal Maker permitted this.
This passage in the Tosefta deals with three kinds of therapy: ichor, a cup of roots, and mei deqalim. Unlike the Mishna quoted above which prohibits mei deqalim on Shabbat, the Tosefta permits it. Perhaps the Tosefta is only referring to quenching the thirst.
In any event, we assume that the rinsing of the sandal in the context of the Tosefta is some kind of treatment for external lesions caused by rubbing the skin. The liquids referred to are therapeutic for skin conditions.
C. Drinking Mineral Water on Hol ha-Mo’ed
The Tosefta (Mo’ed Qatan, ed. Lieberman, 2:10) reports that the Talmudic sages were in doubt about drinking mei deqalim on Hol ha-Mo’ed until Rabbi Akiva, one of the greatest of the Tanna’im, declared it to be permitted:
One may drink ichor, mei deqalim, and a cup of roots on Hol ha-Mo’ed. At first they said: One may not drink ichor, mei deqalim, or a cup of roots on Hol ha-Mo’ed. Then Rabbi Akiva came and taught that one may drink ichor, mei deqalim, and a cup of roots on Hol ha-Mo’ed.
According to Rabbi Abraham Bornstein of Sochaczew (1839-1910), the prohibition to drink mineral water is based on the fear that because of its bitter taste it would interfere with rejoicing during the festival. Further, its therapeutic effect does not take effect immediately. Therefore, its therapeutic effect does not enhance the festival.
D. The Blessing on Therapeutic Spring Water
Drinking spring water gave rise to the fundamental question of whether to pronounce a blessing. And if so, how to formulate the blessing. Blessings on beverages were first discussed in the Palestinian Talmud (Brachot 6:8; folio 10d):
The blessing on drinking water when thirsty is she-ha-kol nihye bi-dvaro.
Rabbi Yona said: Aside from mei deqarim.
Rabbi Yosi said: Any water drunk for thirst.
Rabbi Abbun said: Drinking mei deqarim requires the blessing barukh she-bara mei refu’ot.
According to Rabbi Yona, one does not recite the blessing she-ha-kol nihye bi-dvaro when drinking spring water for therapeutic purposes. Perhaps this is because of its taste or because of the harm it does to the body, viz. the piercing of the gall bladder, as explained in the Babylonian Talmud above.
According to Rabbi Yosi, one does recite the blessing she-ha-kol nihye bi-dvaro when quenching the thirst with spring water.
Rabbi Abbun, on the other hand, holds that such water has its own special blessing connected with its therapeutic use: barukh she-bara mei refu’ot (“blessed be He who hath created therapeutic waters).
The blessing on spring water is not mentioned in the Babylonian Talmud. Nor is it mentioned in the works of Rambam, the Tur, or R. Yosef Karo.
Rabbi Yaakov Etlinger (Germany, 1798-1871) discusses the blessing on mineral water in response to a question he received in the year 1847 from Rabbi Bamberger of Wuerzburg. In summary, the question was as follows:
The question revolves around drinking spring water, called mineral water, for therapeutic purposes. Is a blessing required?
In response, Rabbi Etlinger surveyed the kinds of mineral water known to him, their medical uses, and the corresponding halacha in each case:
There are three categories of therapeutic water. Some drink tasteless water from the wells for therapeutic purposes in order to cool the blood. Some well-known drink spring water that tastes good. And some drink bitter or salty water that tastes bad.
It therefore seems to me that we must make the following distinction: drinking bitter water or tasteless well water for therapeutic purposes requires no blessing. But drinking good tasting water requires a blessing even if drunk for therapeutic purposes. This is similar to any other good tasting beverage that requires a blessing even if drunk for therapeutic purposes.
Rabbi Etlinger emphasizes that the principal point in deciding whether to pronounce a blessing on beverages or foods is their taste. This is because the blessings were instituted whenever there is enjoyment in eating or drinking.
It follows that medicines in principle require blessings when they taste good. Therefore, Rabbi Etlinger concludes that (a) tasteless spring water drunk only to “cool the blood” requires no blessing because it does not taste good; (b) good tasting water requires a blessing; and (c) bitter or salty water tastes bad and therefore requires no blessing.
A similar question touching on the taste of spring water was directed to Rabbi Hayyim ben Mordechai Sofer (1821-1886), the author of Kol Sofer:
A certain rabbinic scholar asked me at Carlsbad about sugar. His illness prevents him pronouncing a blessing over sugar. Is he required to pronounce a blessing before drinking hot water?
I answered that he should not pronounce a blessing because his sole purpose in drinking hot water is therapeutic and no one drinks it to quench thirst.
He asked: if so, why is it permitted to drink hot water on Shabbat? Is it not clear that the hot water is therapeutic and therefore prohibited on Shabbat?
I said: Perhaps therapy is only prohibited on Shabbat if the therapeutic effect is immediate, as in the case of mei deqalim, vinegar, etc. But the waters of Carslbad do not provide instant results. Rather, the beneficial result comes only after around a month of drinking several cups per day. Therefore, such therapy is not prohibited on Shabbat even though the water drunk on Shabbat is part of the ongoing therapy.
In the Middle Ages, as sugar was disseminated through the Near East and Europe, it was used in the preparation of medicines. This was due both to its nutritional value and its sweetness, which improves the bitter taste of many medicines.
The questioner did not know whether to recite a blessing on the sugared water because his health condition made it unhealthy to drink it. Therefore, he was forced to drink the water as it is.
Rabbi Sofer said not to recite any blessing on the waters because it was intended to be therapeutic and tasted bitter In the course of the responsum, the rabbi mentioned another aspect of hydrotherapy that reveals something about the way the water was used and the relationship between therapy and the laws of Shabbat
In response to the question “why is it permitted to drink the water on Shabbat?” since it is therapeutic, the rabbi answered that the water is not immediately effective. Instead of taking effect on Shabbat itself, the effect is apparent only after some time. This means that the water treatment produces long-range results.
In some cases, therapeutic considerations required the patient to drink the mineral water slowly, with interruptions. Rabbi Yosef Shaul Nathansohn (Poland, 1810-1875) discussed the question of physicians prescribing such water semiannually. In such a case must the patient pronounce a new blessing each half year?
Regarding someone who drinks spring water for therapeutic purposes with the advice of a physician and must wait half a year between doses.
Rabbi Nathansohn decided that he must recite a blessing on every individual cup because the half-year waiting period between doses is considered an interruption.
Other authorities, however, disagree and hold that a single blessing covers all the cups.
II. Bathing in Spring Water and Sea Water
Bathing on Shabbat and the Prohibition of Medical Treatment
Talmudic and mishnaic passages deal with therapeutic bathing in several contexts: thermal baths, salty mikva’ot of various standards, and foul steeping pools.
The Tosefta (Shabbat, ed. Lieberman, 12:13) distinguishes between different sources of water when discussing the permissibility of bathing on Shabbat:
It is permitted to bath in the waters of Tiberias and in the Great Sea [i.e., the Mediterranean], but not in steeping pools [used for soaking flax] and not in the Sea of Sodom [i.e., the Dead Sea].
When? Whenever the purpose is therapeutic. If the purpose is ritual purity, bathing is permitted.
The Tosefta permits bathing in therapeutic springs and in the Mediterranean on Shabbat because their waters are suitable for healthy people as well. Therefore anyone bathing there does not create the impression of engaging in therapy.
On the other hand, bathing in the Dead Sea or in a foul steeping pool is prohibited because it is clear that the only purpose of the bathing is therapeutic, unless one’s purpose is ritual purity.
This halacha is quoted in the Palestinian Talmud (Shabbat 14:3, folio 14c) in a slightly different version:
We bath in the Great Sea and in the Waters of Tiberias even though the purpose is therapeutic, but not in steeping pools and not in the Waters of Sodom.
When? Whenever the purpose is therapeutic. But whenever the purpose is ritual purity, bathing is permitted.
The Palestinian Talmud emphasizes that bathing in the Mediteranean and the Hot Springs of Tiberias is permitted even if it is intended to be therapeutic because other, healthy people are bathing there solely for pleasure.
On the other hand, bathing in steeping pools or in the Dead Sea is not common for healthy people. Therefore bathing there is prohibited if the purpose is solely therapeutic.
In the Babylonian Talmud (Shabbat 109a-b) there are several more points of understanding regarding therapeutic bathing:
a. Health Spas visited only by the Ill and those visited by Healthy Patrons
It is permitted to bath in the Gader Hot Springs, which are salty, because healthy people also bath there. Therefore, it is not apparent that any specific person is bathing for therapeutic purposes. The Springs of Hamatan and Assia were frequented by healthy people. Therefore, it was permitted to bath there on Shabbat.
b. Clear Water and Foul Water
Bathing is permitted in the Mediteranean in “nice water,” viz. in areas where the water is clear and clean. This is because healthy people bath there for pleasure or for hygiene.
On the other hand, bathing in foul sea water, such as areas around reefs, where there is less flow and more sea weeds, is prohibited because it is clear that the purpose of bathing is therapeutic as such water contained substances vital for health
c. Duration of Bathing
Remaining in the Dead Sea or in a steeping pool for a long time clearly indicates therapeutic intention, as in cases of skin disease. However, if the bather remains in the water only briefly, he creates the impression of non-therapeutic bathing.
The Talmudic sources deal with the duration of bathing in the Dead Sea and in steeping pools. The medieval halachic authorities disagree regarding hot springs. Some hold that the prohibition in hot springs applies only to people who remain in the water for a relatively long time. Others prohibit even brief bathing in hot springs. Still others hold that even long immersion is permitted.
On the other hand, some modern authorities claim that a patient suffering from a “rash” (i.e., lesion) on his head is permitted to bath there only briefly because otherwise it would be clear that his intention is therapeutic.
According to the stricter opinion, any spring which is clearly used for therapeutic bathing is prohibited on Shabbat even for brief immersion because even brief immersion is clearly intended to be therapeutic.
Rabbi Raphael Meldola, the rabbi of Pisa, Italy, in the beginning of the eighteenth century, severely criticized the Jews who visited therapeutic baths on Shabbat:
There are now many ignorant Jews who go every year to health spas with natural and artificial baths all over this country. They have convinced themselves that it is permitted to bath there and even to remain in the water for a long time on Shabbat…
I do not know where they found such a leniency to bath on Shabbat in hot water for therapeutic purposes…. for these baths are used all year round only because of their therapeutic properties. That is why they are so expensive.
I hereby testify that I have strongly protested against this, but without any success.
Rabbi Raphael Meldona claimed that the baths were in the possession of wealthy local residents who opened them to the general public at certain times of the year when the water contained therapeutic substances. At such times, the patrons streamed to the baths and paid dearly for their therapy.
Rabbi Raphael objected. But his words fell on deaf ears.
Rabbi Raphael was not alone in the battle. Other Italian rabbis stood by his side in denouncing therapeutic bathing on Shabbat. One of them was Rabbi Raphael Baruch, the rabbi of Livorno. Rabbi Raphael Meldona added Rabbi Raphael Baruch’s letter to his own responsa.
Rabbi Raphael Baruch also claimed that the bathing in those baths was clearly motivated by therapeutic intentions, not pleasure. That is why people visit the baths during a limited time:
Those baths are different because they are closed all year and no one goes there aside from a few days every year when they are therapeutically effective. Then they go and spend a lot of money for the cure.
In Rabbi Yaakov Sofer’s encyclopedic work Kaf ha-Hayyim (Bagdad and Israel, 19th-20th cent.), we find a summary of the various aspects of therapeutic bathing in hot springs on Shabbat. According to Rabbi Sofer, the prohibition of bathing in therapeutic springs on Shabbat applies to relatively healthy people who suffer from simple aches and pains. Those who are indeed ill, however, are permitted to bath there even if their condition is not life threatening.
Further, bathing in the spring is permitted if the patient requires treatment specifically even on Shabbat and refraining from treatment would exasperate his condition.
If, on the other hand, refraining from treatment on Shabbat would merely delay his cure, but not exasperate his condition, bathing in the hot springs is prohibited.
Therapeutic Bathing on Fast Days
Bathing on the Ninth of Av and Yom Kippur is prohibited (Yoma 8:1). However, only pleasurable bathing is prohibited; washing or rinsing the body for purposes of cleanliness is permitted.
The Palestinian Talmud discusses therapeutic bathing in the Hot Springs of Tiberias on Fast Days:
Shmuel bar Abba had a rash He went as asked Rabbi Yassa whether he might wash.
He asked: If he does not wash, might he die?
They responded: Yes.
He said: Indeed he may wash even on the Ninth of Av and on Yom Kippur.
Shmuel had a rash and asked Rabbi Yassa whether he was permitted to bath. Rabbi Assa claimed that in light of the threat to Shmuel’s life, bathing was permitted both on the Ninth of Av and on Yom Kippur, both of which are severe fast days.
Although the Talmudic story creates the impression that it is referring to ordinary bathing, it might actually be referring to therapeutic bathing in health springs.
According to Talmudic sources, the treatment for “rashes” (Acne) included anointing the skin with oil and immersion in therapeutic springs. This is clear in a passage in the Babylonian Talmud (Shabbat 109b):
One bathes in the Waters of Tiberias and in steeping pools and in the Dead Sea even when suffering from a rash on the head.
III. Applying Therapeutic Mud and Bathing in Mud
In addition to the use of mineral water, the mud from springs also had medical properties. In technical language, such mud is called “piloma.”
The Mishna (Shabbat 22:6) stated:
It is prohibited to go down into the keroma (wrestling ground) on Shabbat.
In the Talmudic explanation of this Misha (Shabbat folio 147b) we learn that the Mishna is referring to immersing the body in mud for therapeutic purposes:
Rabbi Hiyya bar Abba said in the name of Rabbi Yohanan: It is prohibited to stand on the mud [of the hot springs] at Diosmsith because it is therapeutic.
This implies that mud baths are prohibited at hot springs because such bathing is therapeutic.
Medieval rabbis explained the medical benefits of mud bathing in different ways. Rabbeinu Hannanel (North Africa, 980-1050) explained that mud affects the bowels:
Under the water there is mud. Some say that bathing there is cooling and that the water loosens the bowels.
He means that immersion in the mud cools the body, increases the activity of the bowels, and loosens them.
According to Maimonides, mud is therapeutic because it caused increased sweating. But it is not clear if this is because of the heat of the mud from thermal springs or because of bodily movements that accompany immersion in mud.
Medical use of mud is common in Israel to this very day. Zev Vilnay related that in the area around Sheikh Abraq there is a certain spring surrounded by mud. The Arabs call it al-matba’a, meaning “place of immersion.” Many Arabs go there and immerse themselves, occasionally up to their necks. It is their belief that such immersion is a panacea and even cures infertility.
Summary and Conclusions
Medical treatments in health springs have given rise to a number of halachic issues since the days of the Talmudic sages through contemporary times. Three principle therapeutic practices come under discussion: (a) therapeutic bathing; (b) mud baths; (c) drinking mineral water.
Medical treatments connected with bathing in spring water are discussed in the context of the prohibition of healing on Shabbat and the prohibition of bathing on fast days.
As far as Shabbat is concerned, the governing principle prohibits any source of water that is clearly used for therapeutic purposes (Dead Sea, foul steeping pools, etc.) unless healthy people also go there for enjoyment or for hygiene.
As far as fast days are concerned, there were rabbis who permitted therapeutic bathing as long as the purpose of bathing is not enjoyment. Mud baths are discussed in connection with Shabbat.
The medical science that underlay these therapies posited that mud causes diarrhea and sweating, both of which were thought to be healthy physiological processes.
Drinking mineral water as therapy for internal problems is discussed in the following contexts: the laws of ritual impurity which were relevant in the days of the Second Temple; drinking therapeutic beverages on Shabbat; drinking unpalatable beverages during Hol ha-Mo’ed; the laws of blessings.
The question of blessings reflects the differences between the various types of mineral water. Some mineral water tastes good, and therefore requires a blessing. Other mineral water tastes bad. The quality of the water and the method of treatment influenced the decision regarding the appropriateness of the blessing.
Foul or bitter mineral water would be drunk with interruptions between the doses. Therefore, some held that due to the interruptions each cup requires a new blessing.
In this article we have dealt with the halachic problems directly touching upon medical treatment at hot springs. But it important to note that we have not discussed other problematic areas that arise indirectly.
Among the problems we have not dealt with are: squeezing water from towels on Shabbat; carrying towels to a spring on Shabbat; swimming; frequently springs dedicated to idol worship; straying from a religious life style; influence of non-Jewish cultural values; desecration of Shabbat; lessening of Torah Study; and the availability of kosher food.
There are also halachic problems which, as far as I know, are not discussed in medieval rabbinic literature even though they in fact existed in those days. For example, men and women bathing together, which was quite common in the Middle Ages, especially in Germany. Such mixed bathing involved much revelry and immodesty and was accompanied by music and the consumption of wine.
Major changes in the fabric of modern society have exacerbated the problems of immodesty in mixed bathing. Further, technological developments have led to new problems of desecrating Shabbat through the use of electrical devices, such as pumps, lighting, etc.
 Medical use of health springs in Israel has been discussed in various scholarly forums. For example, see A.S. Hirschberg, “Mekomot ha-Marpe be-Erets Yisrael,” in Ha-Tekufa 6 (5680), pp 242-244; M. Buchmann, “Mi-Toldot Hammei Teverya,” in Erets Kineret (publ.: WZO, Jerusalem, 5711), pp 157-166; S. Twig, “Merhatsot marpe be-Yisrael,” in Kardom 1, 6 (1979), pp. 27-28; Y. Hirschfeld, “ha-Merhatsot ha-Romiyyim,” in Derech Erets (Tel Aviv, 5743), pp. 209-213; Y. Hirschfeld, “Mekom Mayim Yafim,” in Sekira Historit Archiologit, Ariel 55-56 (1988), pp. 9-30; E. Yekutieli-Cohen, Perakim mi-Toldot Hammei Teverya, Mi-Tuv Teverya 6 (5748), pp. 22-27. On health spas in other parts of the world, see references infra.
 See A. Dworzecki, Hammei Marpe be-Erets Yisrael, Doc. Diss., Hebrew University, 5752, pp. 14-19; M. Buchmann, Tverya u-Maayanoteiha ha-hammim, (Tverya, 5716), pp. 2-5.
 Heath spas in Israel have been described by geographers and pilgrims through the generations. The impressions of medieval visitors are surveyed by A. Lev, Samemei ha-Marpe (Tel Aviv, 5762), p. 53.
 See Y. Kolton, “Maayanot le-Hofei Yam ha-Melah,” in Midbar Yehuda (ed. S. Ilan; publ.: ha-Hevra le-Hagganat ha-Teva; n.d.), pp. 66-67.
 See. R. Yankelovits, “Hammei Teverya,” Mi-Tuv Teverya 6 (5748), p. 16.
 See. A. Dworzecki, supra n.2, pp. 136-142; Buchmann, supra n. 2, p 29.
 A. Dworzecki, “Seggulat Hammei ha-Marpe,” in 11th World Conference for Jewish Studies (Sect. 2, vol. 1; Jerusalem, 5754), pp. 40-42. See further E. Dvorjetski, “Medical Hot Springs in Eretz-Israel,” in ARAM Periodical 4 (1992), pp. 425-449.
 Health spas around the Dead Sea have been described by Greek and Roman writers. They mentioned the characteristics of the spas and even recommended bathing there. For example, Pliny the Elder mentions the medical value of the springs of Kalliroë in Transjordan (Naturalis Historia, 74,5). See further Dworzecki, supra n. 7, p. 43.
 See Lev, supra n. 3, p. 53
 For example, Rabbi Sh. Swadron (1835-1911) discussed divorcing a weak wife suffering from a severe cough who had been referred to therapeutic baths (Resp. Maharsham 3:327).
 See, for example, Rabbi Ts. Flekeles, Resp. Teshuva mi-Ahava 1:26 and 1:57.
 Rabbi Yaakov Moelin, Resp. Maharil ha-Hadashot, 204:2.
 Resp. Maharsham 4:142 and 6:83; Rabbi A. Bornstein, Resp. Avnei Nezer Even ha-Ezer 67 and O.H. 395.
 Rabbi Eshtori ha-Parhi, Sefer Kaftor va-Ferah, ch. 7.
 See L. Kourland, “Maayanot Refu’iyyim,” in Enc. Ivr. 24, p 47.
 Summarized in Sh.Y. Zevin (ed.), Enc. Talm. 16, pp. 44-52.
 In various Talmudic sources there are reports of Sages going for cures at health spas. See, for example, Pal. Talm. Shvi’it 9:1 (=folio 38d) and Kohelet Rabba 5:14.
 This discussion involves the Passover sacrifice which must be roasted or, perhaps, cooked in a hot spring. There are no such hot springs in the Jerusalem area. See Enc. Talm., supra n. 16, s.v. hammei teverya, p. 45.
 Some hold that this liquid derives from date palms. Regarding the expression mei deqalim, see I. Loew, Die Flora der Juden 2:346.
 Z Vilnay, Aggadot Erets Yisrael, pp. 304-305.
 Tamar Hindi was used as purgative in the Middle Ages as well. See, for example, Rabbi Menahem ibn Zerah, Tseida la-Derech, 1:3, ch. 10, folio 31a.
 R. Moshe ben Maimon, Hanhagat ha-Bri’ut (ed. S. Munter), p. 47, n. 67.
 Cf. Mishna Torah, Hilchot Shabbat 21:29, where only bathing, not drinking, is considered purgative. Rabbi Moshe ben Nachman ascribes other curative powers to water: “The water of the hot springs of Tiberias is fit to drink. It is not bitter but only the sick drink it (Milhemet ha-Shem, Shabbat 18a in the pagination of the Rif). Therapeutic drinking of the water from the hot springs of Tiberias was known in the 12th century as evidenced by the pottery used for the purpose. Such pottery has been found in the building used by patients being treated there. An inscription found on the pottery attests to the waters effects on the stomach. See A. Dworzecki, “Terumat ha-geniza ha-kahirit le-heker hammei ha-mirpa,” in 12th World Conference for Jewish Studies, Pt. 2, p 87
 Some surmise that these cups were the kasayya tiveriyya mentioned in the Talmud (Nidda 21a). See Y. Schwarz, “Hayyei yom yom be-Tverya,” in Idan 11 (1988), p. 1-4.
 According to the Babylonian Talmud (Shabbat 147b), the beverages were effective only between Passover and Shavuot. It must be assumed that during this period of time the springs produced a greater flow with a higher mineral concentration.
 The word translated here as “ichor” seems to refer to a liquid derived from organic manure or a product of its fermentation; cf. German Jauche. As we shall see later, foul liquids were often considered therapeutically effective.
 “Cup of roots”is a medical beverage used to treat jaundice and to prevent pregnancy (Shabbat 110a).
 According to the Tosefta (Terumot, ed. Lieberman, 10:11, rinsing the sandal was intended to soften it.
 This is the halachic decision of the Beit Yosef (O.H. 432).
 See, for example, Resp. Avnei Nezer (O.H. 395).
 This is the idea of Rabbi Eliezer Valdinberg: “Perhaps this is why no blessing is pronounced on them because drinking them pierces the gall bladder.” See Rabbi Eliezer Yehuda Valdinberg, Resp. Tsits Eliezer 12:1.
 Regarding the blessing to be said over mineral water see, for example, M. Benyahu, Ma’amarim be-refu’a le-Rabbi Raphael Mordechai Malki, p. 156.
 And see Resp. Tsits Eliezer 8:15, ch. 15.
 Sefer Kol Sofer (Muncacz, 5641) ad Shabbat 14:68.
 Regarding the use of sugar in sweetening medicines, see A.O. Shemesh, “Kitvei ha-Rishonim ve-ha-Aharonim,” in Korot 16, pp. 84-85.
 Divrei Sha’ul (i.e., Sefer Yosef Da’at; Lvov, 5638-5639), no. 23.
 Rabbi Sh. Schwadron, Resp. Maharsham 6:38.
 There were a number of steps in preparing flax fibers: the stalks were dried in the sun. Then they severed the seeds from the stalk. The stalks were then soaked in water to soften them. They were removed from the water, squeezed and dried. The next step was nipputs, grinding the stalks to remove the fibers. Finally, the fibers were combed in order to clean them. See A.S Hirschberg, Hayye ha-Tarbut be-Tefufat ha-Mishna ve-ha-Talmud (Warsaw, 6684), pp. 71-78.
 In the Tosefta (ed. Zuckermandel; Tohorot 6:78) we find mention of the hot springs at Hamatan. See Sh. Lieberman, Tosefet Rishonim 4.
 Regarding Assia, see Hullin 48a
 Tur (O.H. 326).
 Bayit Hadash O.H. 326. Cf. Eliyahu Rabba, ibid., who wrote that only therapeutic bathing is customary there.
 Rabbi Sh. Z. of Liadi, Shulchan Aruch 326:48.
 Rabbi Raphael Meldola, Resp. Mayim Rabbim, O.H. 1:25.
 Resp. Mayim Rabbim 26.
 Rabbi Yaakov Sofer, Kaf ha-Hayyim, O.H. 328:253.
 Pal. Talm. Mo’ed Katan 3:5 (folio 82d).
 In accord with this principle many authorities through the generations have permitted bathing on the Ninth of Av for those suffering from any illness. See, for example, Rabbi Yosef ben Moshe (15th century) who permitted bathing for those suffering from the disease called zand (Leket Yosher, p. 109, sect. b).
 S. Munter identified this disease as acne. See his “Munahei Mahalot ha-Or” in HaRefu’ah 16 (5698). p. 3.
 See, for example, Tosefta Trumot (ed. Lieberman; 9:14). Cf. ibid. Shvi’it 6:4.
 Regarding piloma, see Sh. Lieberman, Yevanim ve-Yevanut be-Erets Yisrael, p. 71, and M. Buchmann, “The Nature of Piloma,” in Acta Medica Orientalia 14 (1955), pp.287-292.
 This explanation is found in Rabbi Nathan of Rome’s Aruch (ed. Kohut), s.v. plm.
 Purging the stomach was considered a physically therapeutic act. Cf. Berachot 57b.
 Regarding the healthfulness of sweating, see J. Preuss, Biblisch- Talmudische Medizin, pp. 536-537.
 Z. Vilnay, Aggadot Erets Yisrael: ha-Shefeila, ha-Hof, ha-Negev, ha-Galil, p 135.
 See Shabbat 22:5; Rabbi Yaakov Reischer, Resp. Shevut Yaakov 2:7
 Regarding the concern of gentile practices at spas, see Hirschberg, Mekomot ha-Mirpa be-Erets Yisrael, pp. 242-244.
 Shabbat 147b.
 Resp. Mayim Rabbim 25-27.
 See Rabbi Hayyim Elazar Shapira of Muncacz, Sefer Darchei Hayyim ve-Shalom 564. See also his Minhat Elazar 5:31 and Rabbi Y. Weiss, Minhat Yitshaq 10:92.
 For example, the spa at Leukerbad in Switzerland (depicted in the woodcut by Hans Bosch the Elder) and the therapeutic baths of Plombières (woodcut by de Valna, Jutna, Venice, 1553). On the other hand, a woodcut from the year 1556 showing therapeutic baths at Piermonte indicated separation of the sexes. See R. Margutta, Toledot ha-Refu’ah (Jersualem, 5761), pp. 66-67.