The normal approach in medicine is reductionist. But many phenomena cannot be described by this and need a systemic concept. Unfortunately, modern medicine hardly makes use of systemics theory. On the other hand, a lot of medical observations in the past and in alternative therapies are in line with systemic concepts. Using these old and alternative sources, we should be able to develop a more specific theory of how therapy is working in an human understood as a system.
This paper, brings together ideas and observations of Hippocratic medicine, therapies in spa (cure-therapy), homeopathy, chronobiology, systemic psychotherapy and systems theory. Conclusively, it gives an outline of how a systemic medicine would look.
Keywords: Systems theory, Hippocratic medicine, alternative medicine, chronobiology, systemic psychotherapy
What we call disease or ‘pathological mechanism’ is mostly a result of a partial research, an analysis of a component of the whole. To depict or to analyse the entirety is impossible because it is too complex. Reductionism enables a standardised procedure on account of limited parameters. Another advantage of a small frame of observation is that causal effects can be isolated, or in other words: that the concept of cause and effect can be used.
In order to apply this analytic approach of reductionism, the following two requirements must be met: “The first is that interactions between ‘parts’ be non-existent or weak enough to be neglected for a certain research purpose. Only under this condition can the parts be ‘worked out,’ actually, logically and mathematically, and then be ‘put together.’ The second condition is that the relations describing the behaviour of parts be linear; only then is the condition of sumativity given, i.e., an equation describing the behaviour of the total is of the same form as the equations describing the behaviour of the parts; partial processes can be superimposed to obtain the total process, etc.” (Bertalanffy, 1969, p.19).
Linear and non-linear processes are depicted in diagram 1 (Rosslenbroich, 2001).
Mechanisms in medicine are normally described corresponding to diagram a. Diagram b and c still work in a reductionist concept according to the demands for linearity as phrased by Bertalanffy. They are not so popular in research, probably because of their complexity. As soon as circular processes (diagram d) are involved, we no longer have a clear pattern of cause and reaction. If three or more such circular mechanisms are interconnected we have created (technically speaking) a so-called non trivial machine (von Foerster, 1991; von Bertalanffy, 1969, p. 20). These machines, although totally determined, can not be analysed nor foreseen in their order of events. As the living organism does not fulfil the criteria for linearity, we have in humans a situation, which, in principle, cannot be analysed.
That the results of reductionist research are so reliable (that blood sugar is always regulated to the same level, that an antihypertensive drug works every day the same, that a depressive person is reliably depressed) is due to the recursive cycles of self regulation. Nevertheless, a mechanism in medicine is nothing more than a partial model, because we never know if other mechanisms of regulation will not alter the observed function. Sacks in his foreword of Awakenings which is so to say a textbook of the limitations of reductionist medicine cites Liurja who gave L-DOPA six times to a patient and six times she reacted differently (Sacks, 1990). It must always be examined whether and to what extent the model corresponds with the observations. There are always unexpected reactions, that can’t be explained with linear models. Thus, it has been proved in experiments with animals that an extreme nutrition deficiency does not lead to the symptoms of an avitaminosis. This occurs only in giving vitamins and vanishes again in leaving them out (Kollath, 1983, pp 111-112, 191-196). Kuhn calls such a failure of explanatory models an ‘irregularity of normal science’, a situation that can’t be explained adequately by the current ‘paradigm’(Kuhn, 1962).
As reductionist analysis has only a limited validity for the whole, it follows that therapies based on reductionist models can not be predicted properly. Sometimes these therapies work as expected, sometimes they work to some extent, sometimes they work totally differently, sometimes they don’t work at all. The more mono-causal the mechanism and the correspondent therapy, the more appropriate it is. The therapy of diabetes type 1 follows the quite simple concept of administering the insulin not produced by the body in the most physiological way, whereas the situation in diabetes type 2 is so complex and involves so many factors that no simple concept leads to satisfactory results.
There have been always other and systemic approaches to medicine. What I call ‘systemic’ here is an understanding of disease as a disturbance of organisation. From this point of view therapy is the attempt to influence the pattern of the organisation. That is not the case with interventions according to diagram a c that lead to a trivial sequence of consequences. When Aspirin is given, we might expect some certain effects and side effects on body temperature, bleeding, stomach tissue etc. As soon as recursive processes (diagram d) are involved, the whole logic changes. By taking a cold shower in the morning we do not expect to lower body temperature elevated during sleep (what is not true). We provoke a reaction to a stimulus. According to the starting point of the organism and the quality of the stimulus we produce a complex and self-referential process.
Therapies in spa work exactly according to these principles. There might be only warm and cold water as therapeutic means, but it can be use it in a virtuous manner as Kneipp did. Just to give an example: If someone is very tired, normally a stimulating bath with herbs (let’s say rosemary) is prescribed. But if the fatigue is a consequence of long stress (stadium of exhaustion in stress theory), a sedative bath (baldrian) produces a near-miracle. The patient in his desire to sleep is unable to leave the bed for nearly one week. But afterwards the symptoms (might it be headache, low back pain, high or low blood pressure) vanish. To explain this we need more sophisticated concepts. Linear patterns of cause and effect just won’t do.
The first known in Western medicine going in this direction was Hippocrates. For him, every disease had different causes, i.e. structure of the countryside, climate and its changes, mood, diet and others (Lichtenthaeler, 1975). All these factors had to be taken into account to come to a conclusion about the situation of a patient, his therapy and prognosis. The body, so was the theory, had to be in a certain humoral equilibrium. The disturbance of this equilibrium led to symptoms like fever or an abscess. Important in Hippocratic medicine was not only the fact of fever, but how it developed, how it changed, whether people sweat, were thirsty etc. A good prognosis had to evaluate all these factors. This is only possible if there is a theory, how these factors are interconnected and Hippocrates probably had one. This enabled him to make accurate prognosis. Individual prognosis today is no scientific issue. It is left to the treating doctor who does it instinctively out of lack of a theoretical pattern.
Hippocratic therapy aimed to change the course of the disease, leading the process in the ‘right’ direction, from worse to better. To achieve this, strategic interventions had to be made, always according to the situation of the patient (his sate of fluids) and the progression of the disease. This is why timing was so important for Hippocrates (“The right time is only a moment”). Timing is no major issue in reductionist medicine.
Hippocratic medicine is known for sparse therapeutic interventions. But that does not mean that effects were minor. In recursive functions already a slight stimulus might provoke major changes during time if the stimulus is able to alter the logic of the recursive function.
One observation of Hippocratic medicine was always a source of amusement for modern scholars. These were the ‘critical days’ (4., 7., 11., 14., 17., 20., 34., 40., and 60. ) where a disease could turn to good or to bad. This was sought of as pure numerical mysticism.
Modern research rehabilitated these ideas a bit. Chronobiology found many different and interconnected rhythms in man. E.g. in spas, complications of all sorts arise on certain critical days. Even deaths follow this pattern as shown in diagram 2 (Hildebrandt, 1986).
This point is worthwhile to stay with it: We are not able to observe rhythms if we have no idea that rhythms might exist. Or as Popper put it: There is nothing more useful than a good theory. But it is even more complicated. These critical days of Hippocrates were often in connection with fever and its phases. As modern medicine is giving in such cases antipyretics, we have no idea what happens with these rhythms. Do they still exist, but unseen? Is the pattern changed? What does this mean for recursive effects, for the processes of disease?
This is a crucial point in understanding systemic medicine. How can we perceive a pattern if we change this pattern by our interventions. Medicine is in a different situation as basic sciences. A physicist might observe some particles in a cyclotron for years, doing the same experiment again and again. Doctors have to act and to change. It takes often years to understand effects, especially long term effects, in medicine.
For example, it was thought important for preterm babies to gain weight, to stimulate development, mineralisation of the bone etc. Thus, a special nutrition was developed. Only lately it was postulated that this kind of nutrition leads to more health problems some decades later, whereas a ‘reduced’ nutrition, such as breast feeding has a protective effect (Singhai, 2003).
Because we always intervene, we often do not overlook the consequences.
A quite disturbing example comes from Hahnemann and it would be unbelievable if Hahnemann were not such an excellent observer in all other cases. Syphilis is a disease that starts at the point of contact, usually the genitals, with an indolent ulcer. This ulcer can not be seen as a local reaction only, because at the same time, there are already bacteraemia and general effects of immune reaction. After some weeks, the ulcer vanishes, leading after a pause of several weeks to secondary syphilis with generalised rush. This stadium vanishes again, and after some years, the third stage with destructions arises. This is how every textbook describes syphilis. Hahnemann maintains that the first ulcer will not vanish if not treated but could stay lifelong if left alone (Hahnemann). Could it really be that all medical textbooks are wrong because the syphilitic ulcer never was ‘untreated’?
Hahnemann concluded that the suppression of a symptom would bring up more severe effects.
In atopic disease, it is known that children with eczema have a quite high possibility to develop asthma in later life. According to Hahnemann this is not naturally so but a consequence of the treatment, or in his terms, of the suppression of the eczema. Hahnemann and Homeopathy hold this true for every symptom. Every disease has the tendency to ‘go deeper’, to create more severe effects somewhere else in the organism if the primary symptoms are suppressed.
The idea of suppression can be judged better by using cybernetic concepts.
Systemic psychotherapy was among the first to use cybernetic principles in medicine. They understood a family as a cybernetic circle in equilibrium, and a symptomatic person as a stabilising tool to this equilibrium. If i.e. a couple is ready to divorce, an asthmatic or hyperkintic child could keep them together. Whenever the parents are likely to have more or less distance as usual (set point), the child becomes symptomatic (effector) to bring the family to the old balance. Every intervention to change such a family balance from outside would provoke a reaction of the system (not necessarily from the child) against this change, as long as the set point is left unchanged. The right strategy in such a situation would be to ‘prescribe the symptom’ thus confusing the system and leaving room for a major change. (Haley, 1963) A vanishing of a symptom without structural change was called first order therapy, because we would expect new and other symptoms of the system ‘family’ when the hyperkinetic child becomes calmer. Second order therapy was sought of as a change in the structure of the family.
These concepts have been mostly abandoned out of two main reasons. First: Families or living systems are more complex and consist of many interconnected cybernetic circles. As three circles already constitute a non-trivial machine the reaction of such a system is in a way unpredictable. Second: The concept of a cybernetic circle in family behaviour does not exist as such, but is a result of an observer who defines all the parameters. So called ‘postmodern psychotherapy’ took a more nihilistic attitude, denying the possibility of defining such recursions, something that was falsely called ‘second order cybernetics’.
Although systems do not react in the simple manner of a cybernetic cycle, recursive effects have a stabilising effect, something that is true both for the thyroid gland and for families.
If we look again at atopic disease we find an eczema in the bend of the knees and the elbows for months or even years. There must be a kind of regulating ‘set point’. It is not important that the ‘set point’ does not exist as such but is an expression of interconnected recursive processes. For example, perception is not the result of a homunculus in the brain who does the job, but it is a structural phenomenon; we postulate a consistent perception. Likewise, families are governed by so called ‘myths’ that exist although nobody imposes and controls them. This self-regulating principle is also true on the cellular level. In primary syphilis there is probably no centre deciding on the ulcer. But as the immune response is always the same, there is a patter of response triggered by the stimulus of Treponema pallidum. The practical expression as ulcer is structural self-organisation of the bacterium and human immune response.
What happens if we intervene in such a situation, changing the structure of the self-organization? When we treat a hyperkinetic child with tranquilliser or an eczema with cortisone? Is it a first order therapy, a ‘real’ therapy, or is it according to Hahnemann a suppression?
Already Bateson was concerned about this crucial problem in medicine and social science. In his article Effects of Conscious Purpose on Human Adaptation (Bateson, 1972), he claimed that in complex systems, a subsystem unable to regenerate has the tendency to develop an exponential spin. That is, on a formal level, an exact description of allergic reactions (hay fever or asthma) after Hahnemannian suppression.
This is but one similarity between cybernetic or systemic concepts and clinical observations. Another similarity is the ‘initial deterioration’: Every therapy not based on the linear assumption of suppressing a symptom knows the fact that at the beginning of a therapy, symptoms can become worse. This is seen in every spa, in physiotherapy, in homeopathy, acupuncture, and in many other therapies. Reductionist medicine has no explanation, and it is rarely observed at all. Therefore we have no data if and how often this happens after medical prescription. This initial deterioration in a way is proof for a systemic intervention: “If we find overshoot or false start as is the case in many physiological phenomena we may expect this to be a process in an open system with certain predictable mathematical characteristics” (von Bertalanffy, 1969)
How is it possible to know whether something is an initial deterioration or a aggravation of the disease? How can we distinguish between a first order and second order therapy? How do we know if something is a therapy and not a suppression?
It is in a way a similar question how and according to what principles Hippocrates established his prognosis and found the right moment of intervention? What knowledge did he have about complex interconnecting processes?
Some hint gives us the so called Hering’s Rule of Homeopathy. Hering was a German pupil of Hahnemann and brought homeopathy to America in the 19th century. He was the first to systemise observations in the course of a therapy. Hering’s Rule has been refined later but is still connected to his name. As it is a pure phenomenological description of a process, it has nothing to dowith whether homeopathy works or not. It describes, how a therapy goes well or not. It has much in common with the Hippocratic principles, indicating that doctors of different centuries and with different systems of therapy came to similar conclusions.
Hering’s Rule comprises four statements. The fist two are imperative, the other two are more or less guidelines.
1. From the interior to the exterior: This is basically the reversal of Hahnemannian suppression. A therapy goes well, if more severe symptoms vanish and less severe symptoms appear. If asthma becomes better the worsening of the eczema is a good sign. If depression gets better, stomach pain is a good sign and should not be treated or suppressed. If stomach pain gets better back pain might arise and is a good sign. Or if in a common cold the bronchitis is getting better coryza could become worse. This is still seen as an amelioration. There are some quite sophisticated ideas what is seen as ‘inner’ and ‘outer’ (Vithoulkas) If disease develops the other way, it is a suppression and should be treated immediately.
2. From chronic to acute: This is quite similar to the former. As a chronic disease is considered a consequence of suppressed acute disease, the outbreak of an acute bronchitis with fever in a patient with chronic asthma is seen as a step forward. The same is true for an acute headache in chronic migraine, but also for virus infections in a state of fatigue. The initial deterioration could be seen as an acute exacerbation of a chronic state.
3. Backwards in time: First, more recent symptoms have to vanish, then the older ones. Old symptoms and diseases, even if they lie some decades back, might reappear, and is seen as a good prognostic sign.
4. From top to bottom: symptoms should reappear or vanish from top to bottom. I had a patient who didn’t knowHering’s rule, who had started with headache, and within some weeks the pain went down the spine, the legs and left her finally with a pain of the nails of her toes. Although this is seen as a prognostically good sign, rule 3 and 4 are not handled very strictly.
The main question I would like to bring into discussion, is whether these principles are a mere delusion of outsiders. Or do they reflect some fundamental principles of self-organisation leading to a better understanding medicine?
Bateson, G (1972): Steps to an Ecology of Mind, Chandler, San Francisco
Hahnemann, S. (1835): Die chronischen Krankheiten, ihre eigenthümliche Natur und homöopathische Heilung , Arnoldsche Buchhandlung, Dresden, p. 15
Haley, J. (1963): Strategies of Psychotherapy, Grune & Stratton, New York
Hildebrandt, G. (1986): Chronobiologische Grundlagen der Ordnungstherapie, in: W. Brüggemann (ed.) Kneipptherapie, Springer, Berlin, pp. 170-222
Kuhn, T. (1962): The Structure of Scientific Revolution, University of Chicago, Chicago
Lichtenthaeler, C. (1975): Geschichte der Medizin, Vol 1, Deutscher Ärzte-Verlag, Cologne
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Sacks, O. (1990): Awakenings, Harper Collins, New York
Singhai, A., Fewtrell, M., Cole, T., Lucas, A. (2003): Low nutrient intake and early growth for later insulin resistance in adolescents born preterm, Lancet 2003; 361: 1089-97
Vithoulkas, G. (1980): Science of Homeopathy. Grove, New York
Von Bertalanffy, L. (1969): General System Theory, Braziller, New York
Von Foerster, H. (1991) Through the Eyes of the Other, in: Steyer, Frederich (ed.) Research and Reflexivity (F.Steyer, ed.) , Sage, London, pp. 21-28