Treatment

TREATMENT (therapia), the complex of measures aimed at eliminating pathological processes developing in the patient's organism, as well as eliminating or alleviating the suffering and complaints of the sick person. History of the evolution of treatment. Already among cultured peoples of deep antiquity, who had no conception whatsoever of the structure and functions of the living organism, one finds a whole series of therapeutic methods that are still used today. Thus, already more than 10,000 years ago, the Egyptians developed an amazing dietetics as a method of preventing and treating diseases, applied suggestion and hypnosis and prescribed to patients a whole range of medicinal substances of plant, animal and mineral origin, such as castor oil, pomegranate root, henbane, sea onion (Scilla), compounds of zinc, copper, iron and especially alkalis, as well as animal fats, bile and fresh blood. No less high was the therapeutic technique among the Egyptians; medicines were administered internally and in the form of gargles, suppositories, rubs, injections, fumigations and finally in the form of enemas. Surgery and obstetrics (cesarean section, version of the fetus, embryotomy) reached a particularly high degree of development among the Egyptians. The Egyptians had eye doctors, surgeons, gynecologists and sanitary physicians. Therapy was no less highly developed in India (approximately 2,000 years before our era); dietetics here is the basic therapeutic method along with amazingly developed physical exercises in the form of special breathing gymnastics; ancient Indian medicine knew such medicines as mercury, arsenic, sulfur, and used blood as a therapeutic agent; doctors performed laparotomies, lithotomy, performed complex plastic operations on the face. Undoubtedly, conscious or unconscious psychotherapy was especially highly esteemed at all times; Iranian medicine for example (2,000 years before our era) formulates the methods of treatment in the following words: 'Three instruments are there for the physician: word, plants (medicines) and knife', obviously placing psychotherapy in the first place. The oldest medicine, widely using a number of treatment methods obtained purely empirically, at the same time tried to provide them with a philosophical-theoretical basis and considered the main goal of treatment to be the restoration of the body's equilibrium, its harmony, disturbed by disease, and above all harmony between the activity of the body and spirit. Such theories were connected with the concept of the essence of disease, and perhaps the first of them were those that linked the occurrence of disease with the introduction of a foreign living being into the organism or with the influence on man of higher supernatural forces. In fact, treatment, with the exception of individual purely technical branches of it, was in the hands of a strictly closed caste of priests, and mystical ideas about the cause of disease could not but contribute to the success of the psychotherapy of cult servants. This explains the enormous role that religious doctrines played in the treatment of diseases, which assigned such an important place to healing as proof of the power of higher forces over the sick person. As is known, subtly and skillfully applied psychotherapy often ensured significant successes in treatment for servants of religious cults, harmonizing with mystical ideas about the essence of disease and therefore about its treatment with the help of supernatural forces, thereby strengthening the authority and with it the further successes of theurgical priestly therapy. Therefore, preventive and treatment measures against diseases obtained empirically were willingly introduced in the form of laws into religious doctrines, the treatment of the sick person became an instrument of the cult and at the same time of the power of the ruling class over the masses; this was all the more natural since the true causes of diseases were not known at all. Theurgical medicine placed the physician in the ancient world high above the popular masses, surrounding his activity with a mystical aura and thereby at the same time strengthening both the power of religion and the authority of the physician. Hippocratic therapy. The synthesis of the ideas underlying the treatment of the oldest medicine is the teaching of Hippocrates. By this time, in separate schools, two directions of therapy had particularly sharply emerged: speculative and empirical. The representative of the first trend was the Greek medical school of Knidos, of the second-the school of Kos with Hippocrates at its head. The basis of Hippocratic therapy is the idea of the healing power of nature (physis). This idea puts the organism itself at the forefront of the fight against disease, since disease is conceived as the reaction of the organism to certain harmful factors, which are either factors of the external environment or a violation of harmony within the organism caused by an improper mixture of its juices (dyscrasias). Without the participation of the organism itself, no cure is conceivable. The school of Hippocrates puts observation of the patient and his environment and the study of the ways by which the organism itself gets rid of the disease at the basis of treatment. 'It is not the physician who treats the disease, but the organism treats it.' The physician is thus assigned only a modest role as an assistant to nature in the treatment of diseases. However, for this one must first of all know how to observe the organism, take into account the conditions of the occurrence of the disease and have experience in treatment. The physician obtains this experience not through abstract reasoning, but through observation and study of the patient; there are no systems of treatment and theoretical premises for it; each individual case of disease requires its individual treatment and especially an individual diet. Healing agents are obtained not through fruitless reasoning, but thanks to happy chance; they can be found not only by physicians but also by people ignorant of medicine. In order to be able to observe, accumulate experience and apply in practice the healing forces of nature, one must possess the art of healing. However, this art also includes the careful study not only of the patient's organism, but of all his surroundings up to the climate and customs of the country where the patient lives, inclusive. Hippocrates attaches primary importance to nutrition as a therapeutic method, devoting entire treatises to diet and making it dependent on the individuality of the patient, the climate, the time of year and other external conditions of the organism's life. Considering that natura sanat, medicus curat, Hippocrates demands first of all from the physician not to harm the patient in treatment ('nil nocere'). Considering treatment as the art of applying acquired experience, Hippocrates does not consider it obligatory for the physician, before applying a therapeutic agent, to know the mechanism of its effect on the organism. 'The physician has only one task-to treat. And if he succeeds, it is completely indifferent by what path this was achieved for him.' This position of Hippocrates most vividly reflects the empirical therapy of his school. At the same time, Hippocrates considers it insufficient for a physician to know only how to observe and apply in treatment the accumulated experience. The physician must also be a philosopher. And Hippocrates, along with concrete prescriptions of empiricism, gives at the same time certain philosophical premises for treatment, proceeding from his understanding of the essence of health and disease. Health is harmony, expressed in the correctly alternating rhythm of life phenomena, in humoral equilibrium; the violation of this equilibrium and rhythm, disharmony-is disease. Systems of treatment of diseases. Along with the teaching of Hippocrates, the philosophy of Plato and especially Aristotle had no less influence on the development of the treatment of diseases. Aristotle, having a close connection with the school of Knidos, on the basis of developing a huge amount of factual material obtained empirically, sought to scientifically substantiate the essence of disease and its treatment and was the founder of a long series of speculative systems of therapy, which dominated the minds of physicians for 1,500 years. Of the followers of Aristotle, Galen (2nd century of our era) had especially great influence on the development of therapy. Proceeding from the teleological philosophy of Aristotle, Galen made an attempt to provide a theoretical scientific basis for Hippocratic therapy, putting at its foundation his very primitive knowledge of the anatomy and physiology of the human organism. The physician must be active if he sees insufficient ability of the organism to heal. This activity the physician must manifest in a certain system of actions dictated by the stage of the disease and the properties of various medicinal substances; thus the physician regulates the functions of the patient's organism, especially its property to excrete from itself harmful substance (materia peccans), causing disease. Hence the wide application of emetics, laxatives and drastic means, bloodletting and other distracting methods of treatment, having the task of helping the organism to excrete this materia peccans. The views of Galen, which dominated for a long series of centuries, can still easily be traced today in the folk medicine of different countries. The Middle Ages left no noticeable traces in the history of the treatment of the sick person. The ideas of Aristotle and Galen led to the creation of a long series of scholastic schools, and the dominance of the church significantly delayed the progress of therapy, and if it did not become theurgical again, medical schools were forced to completely submit to the influence of the princes of the church and to coordinate their scholastic research with the ideas admitted by the dictatorship of religion. And only Arabic and Hebrew medicine preserved for future generations the treasures of ancient therapy, adding however little to it new original methods of treatment of diseases. Paracelsus put an end to this era, reviving interest in the methods of treatment of Hippocrates and Galen.

He lays the foundation for obtaining chemically derived medicines from various compounds. For Paracelsus, chemistry ceases to be a means of finding the philosopher's stone for turning base metals into gold and preserving health, and becomes a method for obtaining new substances from various compounds for the treatment of disease. Paracelsus was the first to extract the active principles from plants and thereby laid the foundation for pharmaceutical chemistry. But Paracelsus's main contribution to the field of therapy was his struggle against the scholastic systems of disease treatment and the restoration of the authority of Hippocrates, whom he pointed to as the only physician who held a firm position in medicine. The development of medical knowledge in the 16th century, especially in anatomy (Vesalius, Fallopius, etc.), led to significant development of surgery and obstetrics as methods of treatment (Ambroise Paré), and the beginning of the study of natural sciences in the 17th century was reflected in the emergence of new systems of treatment—the iatrophysicists and iatromechanics. According to the iatromechanical system, all diseases are divided into those forming 'acid and alkaline caustics' and, according to the Hippocratic principle of treatment contraria contrariis, should be treated with opposite chemical substances. However, even at this time, the most outstanding physicians treated patients practically, based on the principles of ancient Hippocratic therapy. In the 17th century, the most prominent representative of this trend in therapy was the English physician T. Sydenham (Sydenhara), who restored the principle of Hippocrates that nature, not systems of treatment, heals the sick person; at the beginning of the 18th century, such a physician was Boerhaave in Holland. Next should be mentioned the vitalist Stahl, whose main therapeutic principle is the physician's support of the function of 'anima', the soul, which is the highest regulator of the body, especially in its struggle with disease. This also includes the less prominent vitalists of the 18th century. A special place is occupied by the system of Mesmer, who based himself on the newly emerging doctrine of magnetism and recommended treating all diseases by influencing the 'animal magnetism' through magnets or by magnetizing the patient. It is instructive that this system, despite the sharp opposition of scientific circles, had enormous success among patients. In the first half of the 19th century, vitalistic philosophy still held such a strong grip on the minds of physicians that even the greatest clinicians of the time, such as Broussais, openly spoke of the life force and treatment based on the influence on the life force, and built very poorly founded eclectic therapeutic systems. Only in the second half of the19th century did cellular pathology and the experimental method put an end to purely speculative therapy and create the foundation for modern therapeutic methods of influencing the sick person. Treatment in the second half of the 19th and in the 20th century. The rapid growth of capitalist production led to an unprecedented flourishing of science and technology, to a huge number of discoveries in all fields of knowledge, but especially in the natural sciences—physics, chemistry, and biology. Medicine began to be thoroughly rebuilt on the basis of the great achievements of the natural sciences (anatomy, physiology, and biochemistry) and seemed to begin to free itself from speculative and vitalistic theories and premises in disease treatment. Therapy began to strive to occupy the position of an exact science. In this era, scientifically thinking physicians seemed to free themselves simultaneously from the mystical heritage of the pseudoscientific schools of the 18th century and from the empirical therapy of Hippocrates, trying in their behavior at the patient's bedside to be guided by precise scientific indications dictated by the essence of the pathological process. Abandoning humoral pathology under the influence of the development of the doctrine of the cell and considering the organism as an aggregate of cells, medical thought put cellular and solidary pathology at the foundation of therapy; henceforth, bloodletting in all its forms, distracting methods of treatment such as on the skin (cupping glasses, mustard plasters) and on the stomach and intestines (laxatives, emetics, diaphoretics, and diuretics) are for a long time banished from the clinic. The organism is considered as consisting of separate parts, and therapy acquires the tendency to treat the diseased organ—local organoid therapy; all symptoms of disease, considered from this localist point of view, are regarded as manifestations of harmful processes taking place in the cell and therefore are subject to elimination. Hence, in connection with the rapid growth of chemistry, the discovery of a huge number of pharmaceutical preparations that destroy pathological processes and their manifestations; hence, for example, the fight against fever by strong antipyretic drugs or by the application of cold, even icy baths (for example, in typhus, in pneumonia). Chemistry places in the hands of physicians a colossal number of new means for eliminating many pathological symptoms; there is a lush flourishing of drug therapy; however, at the same time, there grows the conviction in the unnecessariness, uselessness of drugs and therapeutic nihilism as a result of observations of the action of drugs. This nihilism finds its theoretical justification in the Vienna school, which sets itself the goal of only studying the manifestations of disease and considering that the physician should not even dream of influencing it by any means (Skoda, Dietl). Thus, the first attempts to build therapy as an exact science led, along with the expulsion of empirical methods of treatment, as lacking strictly scientific justification, to some negative phenomena. The enormous successes of bacteriology, the doctrine of immunity, serology, endocrinology, and the physiology of the nervous system, in particular the study of the functions of its vegetative part, to a large extent corrected the errors of the era of purely morphological pathological thinking. New ideas of physical chemistry and its role in biology to a large extent strengthened the synthesis of humoral and solidary pathology, and the newest methods of functional diagnosis supplemented morphological pathology with functional and laid the foundation for functional therapy. This progress in medical knowledge opened many new pages of scientific and experimental therapy, enriching in all areas the practical work of the physician. A series of brilliant discoveries in technology on the basis of new achievements in applied chemistry and physics enriched the arsenal of therapeutic means of the physician and gave him in his hands technical possibilities about which physicians of former times could not even dream. The progress of the natural sciences in general and of medical sciences in particular has produced a real revolution in a number of branches of therapy. This includes above all the brilliant successes of surgery, which are the result of the development of bacteriology, pharmacotherapy, and chemistry. A huge number of achievements in technology (optical systems, endoscopy, X-ray diagnostics) significantly expanded the field of surgical intervention and gave rise to a number of new therapeutic methods, enabling the physician to actively intervene in the course of pathological processes in the most deeply lying organs (brain surgery, urology). The successes of bacteriology and the doctrine of immunity gave broad scientific justification to completely new methods of treatment, such as serotherapy, vaccine therapy (see); at the same time, a number of firmly grounded methods of preventive therapy were proposed. On the other hand, the same successes of bacteriology, as well as physical chemistry and biochemistry, gave scientific justification to a number of old methods of treatment, seemingly forever excluded from the physician's arsenal by solidary pathology, and to the clinic return already well-forgotten bloodlettings, blood transfusions, distracting skin treatments, etc. The doctrine of internal secretion gives scientific justification to a number of long-forgotten treatment methods of antiquity and the Middle Ages, such as the therapeutic use of animal organs, seemingly forever thrown out of the physician's therapeutic arsenal together with the mystical premises of their application; it enriches therapy with such means as adrenaline, thyreoidin, and insulin. At the same time, a fortunate circumstance again draws the attention of physicians to the benefit of using individual organs in the treatment of certain diseases, such as the liver in pernicious anemia. The successes of physics and technology give into the hands of physicians many new natural healing forces of nature, a huge arsenal of physical methods of treatment with water, heat, light, electricity (see Hydrotherapy, Pelotherapy, Electotherapy) and still unknown to physicians new types of radiant energy, such as treatment with X-rays and radium (see Radiotherapy and Radium therapy). Types of treatment. The most radical must be considered that therapy which has as its aim the removal from the organism of the pathogenic agent (where it is known). The simplest example of such therapy is the treatment of poisonings by removal or neutralization of the poison or removal of a living parasite from the organism, and the most ancient method of this causal treatment is the expulsion of worms. This also includes so-called specific therapy, which by not yet completely clarified ways affects a number of disease-causing agents, such as quinine in malaria, mercury, iodine, and salvarsan in syphilis, salvarsan in relapsing fever and other spirochetoses, salicylic preparations in acute rheumatism, antitoxin serum in diphtheria, etc. This can also be conditionally included the treatment with some hormones (insulin) or vitamins (in rickets, scurvy). Specific treatment is however applied in a relatively small number of diseases both because the immediate cause of the disease has not yet been established and because of the lack of therapeutic means that eliminate the already known cause of the disease.

Therefore, in practice, the physician most often has only to eliminate and alter the pathological functions of organs that arise as a result of their diseases, and thus promote the restoration of normal activity of these organs. Such therapy is designated as functional, and its application is based on knowledge of the mechanism of origin and pathogenesis of disorders of body functions in a given disease. This includes, for example, the restoration of compensation of cardiac activity in defects and lesions of the heart muscle, when shortness of breath, insomnia, edema, pain in the congested liver, gastrointestinal disorders, and bronchitis are treated not by affecting individual organs, but by acting on the primary cause that caused these phenomena—on cardiac activity, often independently of the etiological factor that caused the heart disease itself. Finally, symptomatic therapy is distinguished, which aims to eliminate the seizures of the disease and the suffering of the patient regardless of their etiology and pathogenesis. This includes a huge number of pharmacotherapeutic and physiotherapeutic means; psychotherapy can also be included in this in its known restrictive understanding. The number of therapeutic means available to the physician for symptomatic therapy is extremely large and varied, and great knowledge and experience are needed to choose the most appropriate method for symptomatic treatment in a given case. Radical and conservative treatment can also be distinguished. Radical treatment is used mainly in surgery, gynecology, otorhinolaryngology, and ophthalmology. However, it is necessary here to distinguish between the truly radical elimination of the disease and its cause from the radical nature of the surgical method itself. Thus, for example, appendectomy in suppurative appendicitis, the creation of an intestinal anastomosis or resection of the intestines in their obstruction, the excision of cancer or fibroids of the uterus, of course, radically cure the disease, just as the excision of any benign tumor or the reduction of a dislocation or the healing of bone fractures, whereas in the removal of the gallbladder with stones or in the excision of a stomach ulcer, radical cure does not occur in all cases, because the cause of the disease is not always eliminated, but only a part of the diseased organ is removed; the same often applies to malignant neoplasms that recur after seemingly radical operations. Conservative treatment is usually understood as the use of non-surgical methods, and in terms of effect (for example, the expulsion of worms), it sometimes by no means yields to so-called radical treatment. Very close to conservative therapy is expectant treatment (therapia exspectativa), which traces its origin to Galen, who recommended that the physician, before actively intervening in the course of the disease process, be convinced of how sufficient the natural tendency of the body (physis) to self-healing is. In a number of infectious diseases, expectant treatment, provided that a certain environment and care for the patient are created, is very beneficial for the patient. Along with the treatment of the patient in the narrow sense of the word, preventive therapy (see Prevention) occupies a special place, which aims not only at social measures preventing diseases in the mass population, but also at a number of individual measures, both protecting a healthy person from disease and aimed at protecting the body from exacerbation or relapse of an already completed pathological process. In contrast to physicians of past epochs, especially the 18th century, the modern physician does not see in any of these numerous types of treatment any obligatory system for himself for treating the disease. In each individual case, depending on the specific features of the case and the individual course of the disease, the physician selects one or another type of treatment, or simultaneously combines different types of it. Thus, in stomach ulcer, a conservative (dietetic) method of treatment can be applied, and with appropriate indications, switch to the radical method (surgical), after which the patient is again subjected to conservative treatment. In pulmonary tuberculosis, the expectant or conservative method of treatment is indicated in some forms and stages of the disease, while in others or in complications, the physician resorts to very active intervention in the same patient, for example, to collapse therapy.

Treatment methods. When carrying out a particular type of treatment, the physician has at his disposal a large number of therapeutic agents and treatment methods. All modern methods of treatment can be divided into three groups (and most often the physician simultaneously uses several types of treatment—combined treatment): the first includes the application of natural (natural) healing agents to the patient's body; the second includes the introduction of artificially obtained medicinal substances into the body (medicinal treatment); the third (which now has mostly only historical interest) includes a number of systems and methods that have no scientific basis and are used either due to falsely understood scientific premises or even with deliberately speculative purposes. The first group consists of dietetics, which is at present the basis for treating most diseases, hydrotherapy with its numerous branches, light therapy, which includes both natural sun therapy (heliotherapy) and the artificial application of all other types of radiant energy (actinotherapy) up to and including treatment with X-rays and radium, electrotherapy with the use of various types of electricity; this also includes the application of thermotherapy up to and including mud therapy. Climatotherapy, sea therapy (thalassotherapy), balneological and spa treatment also belong to this group. Medical gymnastics, medical sports and massage, as well as treatment with air baths (aerotherapy) complete this long list of physiotherapeutic agents available to the physician and used either in the form in which they were recommended by physicians of deep antiquity, or with the help of numerous devices developed by modern science and technology. To these methods should also be added psychotherapy, which stands somewhat separately and constitutes from the very beginning of the treatment of diseases an essential method of the physician's influence on the course of a number of pathological processes. The second group should include treatment with proper medicinal substances—pharmacotherapy. The latter has used in medicine of all times and countries innumerable therapeutic properties of substances of plant, animal, and mineral origin, but thanks to the successes of chemistry and physics, it is now brilliantly completing the work begun by Paracelsus—the extraction of medicinal substances in their pure form from their compounds. The successes of physiology and biological chemistry have significantly expanded and deepened modern pharmacotherapy and made it possible to widely apply, instead of the previous organotherapy, hormones. Pharmacotherapy has led to a significant flourishing of specific therapy and chemotherapy, which aims at the complete elimination of the disease-causing agent from the body (therapia magna sterilisans). To pharmacotherapy can also be attributed the treatment methods that arose under the influence of the successes of bacteriology and the doctrine of immunity: serotherapy, bacteriotherapy (vaccinotherapy) as types of specific protein therapy, and the vast field of non-specific protein therapy as treatment by irritation (so-called Reiztherapie) (see Protein therapy). From this point of view, substitutional (supportive) therapy should also be considered, which introduces into the body in the form of drugs substances that it lacks, for example hydrochloric acid, enzymes (pepsin, pancreatin) and especially the products of the activity of the endocrine glands (hormone therapy). The third group of treatment methods has for the physician on the one hand only historical interest as reflecting the pseudoscientific treatment systems of various epochs, and on the other—as revealing numerous attempts to treat patients by using methods that are completely unfounded, but which nevertheless often have enormous practical success exclusively through the psychotherapeutic path. This area is applied by healers using the 'natural' forces of nature (Naturheilkunde, Naturheilmethoden) and quacks (Kurpfuscher). This includes special water treatment systems (Kneipp, Priessnitz), proposed not by physicians but which forced the scientific development of hydrotherapy, as well as magnetic treatment (mesmerism), treatment with passes, treatment with injections (Baunscheidtism) in its various manifestations, and finally a whole series of psychotherapy systems, such as 'Christian Science' or 'Eddyism' in America, the Guez system and a whole series of charlatan methods, flourishing in a splendid bouquet even today in the largest world centers alongside strictly scientific therapy. Somewhat separate from these treatment methods is nursing care for the sick (hygiene), which at all times has had a great influence on the course of the disease and especially on the prevention of a number of complications that often ultimately decide the outcome of the disease. Not being in essence a treatment method, proper nursing care for the sick, significantly facilitated by the achievements of modern technology, aims to put the body in optimal conditions appropriate to the specific disease and thereby promote recovery. Psychotherapy at first glance occupies a special place as a special treatment method, not belonging to either the first or the second group. But if one recalls the experimentally established facts of the direct influence of the psyche on purely somatic processes (let us name only the experimental works of Pavlov and his school, the works of Heyer, Marx, Glaser, and Hansen and many clinical facts collected in the books of Schwarz, Alkan and many others), it becomes clear that despite all the successes of physio- and pharmacotherapy, the very behavior of the physician toward the patient continues to have the greatest importance as a psychotherapeutic treatment method. The underestimation of psychotherapy by the modern physician, which in fact begins already at the moment of the first meeting with the patient and ends with such special psychotherapeutic methods as hypnosis and psychoanalysis, is sometimes the cause of failure in the application of strictly scientific treatment methods and at the same time one of the reasons for the enormous success of charlatans and quacks. On the question of the so-called 'protective forces' of the body in connection with treatment—see Appropriateness.