Georg Ivanovas From Autism to Humanism - systems theory in medicine
Different methods of CAM have always used hierarchical models to judge how an environmental, inner or therapeutic stimulus influences the regulation of a person. By the help of such models these methods are able to estimate whether a therapeutic intervention leads to an improvement of the health situation or not. Furthermore, they enable the physicians to adjust the therapeutical means according to the observation. Although this is a normal procedure as every therapy is adjusted to the observed reaction (as in chronic headache, diabetes or psychosis), the hierarchical model allows a more detailed understanding of the courses of events. And often it is even possible to establish an individual long term prognosis. Most practitioners have such a theory, anyway. But it is mostly a private, an intuitive theory (chap 6.12).
The best known example of such a model in medical history is the prognosis of Hippocrates (chap. 5.3.c). However, the Hippocratic texts do not reveal the exact procedure how the prognosis is established. Nor is it explained how the understanding of the pattern leads to certain therapeutic interventions. In contrast, different methods of CAM provide quite detailed models combined with the instructions when and how to intervene in the course of events.
This shall be exemplified with two models, one of acupuncture and the other, more detailed, of homeopathy. These examples shall demonstrate how complex observations can be organised, lead to an individual prognosis and instruct the therapist about a further procedure.
The hierarchical model proposed by Chinese medicine and acupuncture is according to the basic paradigm of Chinese medicine precise and relational at the same time. The model says that the ‘cause of the diseases’ (mainly inner or outer stressors) (chap. 5.6.c) ‘penetrate’ the body in a certain order (König/Wancura 1979: 105). They ‘penetrate’ along the line
- skin respiratory organs
- muscle spleen
- tendons liver
- bones kidney
That is, a reaction to cold on the level of the skin and the respiratory organs reveals more stability than when muscles are involved. A rhinitis or a cough are thought of as not so deep rooted as when muscle pain, or even pain of the bones is present. The judgment of the ‘depth of the disease’ informs the therapist what kind of resources are necessary to encounter the unbalanced situation. This system is further refined by the involvement of the meridians which are also ‘penetrated’ in a certain sequence connecting the disturbance with the totality of inner regulation.
The homeopathic model is more functional due to the strategic theoretical background. It is probably the most refined of all known models and has also been accepted by other methods helping them to assess the effect of their therapies. As this model concerns the observation of processes and does not involve the question which therapeutic stimulus is used, it might even provide helpful insights for the orthodox medicine.
The homeopathic model is called ‘Hering’s Rule’ attributed to the homeopath Constantine Hering (1800-1880) although it is not directly by him. It assumes that all kind of expressions of the body are somehow connected, even symptoms from organs without direct pathophysiological relation (headache with gastritis, depression with herpes, asthma with low back pain and so on). Comparable examples of orthodox medicine are syndromes, like Sjögren’s disease or eczema and asthma in atopic disease. But orthodox medicine never considers a functional relation between these symptoms informing us about the inner condition of the patient. Exactly this does Hering’s rule and by that it enables to assess the individual process of a therapy. It helps the therapist to understand when a therapy leads to an improvement of health and when not.
Hering’s rule, exists in different forms. Basically it says that a therapy leads to a better condition when it shows the following characteristics:
- from interior to exterior,
- from chronic to acute,
- backwards in time,
- from top to bottom.
From interior to exterior:
This part of the rule refers to some basic assumptions about an inner hierarchy. A disease is said to be higher in hierarchy (more interior or inner) the more threatening it is for the existence of the person. Lower in the hierarchy (more exterior or outer) is a disease when it does not really impose health problems. A simple skin process is not life threatening and therefore more exterior than asthma. The most inner processes are destructions (cancer, Alzheimer’s disease), the dissolution of personal integrity (schizophrenia, psychosis) and the general decline of strength.
The first part of Hering’s Rule says that a therapy goes well when symptoms on a higher hierarchical level vanish and symptoms on a lower hierarchical level appear. Then the disease goes from interior to exterior. This happens, for example, when asthma goes away and eczema appears, or when a depression goes away and gastritis arise, or when a general weakness (a fatigue syndrome, for example) improves but myosceletal problems appear or intensify. All this is regarded as an improvement of the general health situation and does mostly not induce a change of the therapeutic strategy.
The opposite, suppression, occurs when symptoms on a lower hierarchical level vanish and symptoms on a higher hierarchical level appear. For example when a gastritis improves but the patient becomes more depressed, or when an eczema improves but asthmatic symptoms occur or increase. Then an immediate change of the therapeutic strategy is necessary.
Although this sounds strange for the reductionist trained scientist, the examples of suppression cited before (chap. 6.8) follow exactly this pattern. An example is the therapy of gastritis with acid-suppressives which leading to an increased risk of community-acquired pneumonia (Laheij et al 2004). This is, according to Hering’s Rule, a classical development from exterior to interior, as pneumonia is more life threatening than gastritis. On the other side, a patient with recurring pneumonia, re-establishing a healthy pH, will for some time suffer again of gastritis until he overcomes also this stage and achieves a better equilibrium. The reappearance of gastric disease indicates in this case the termination of pneumonias (from interior to exterior). However, rarely it is possible to find such a related pathophysiological mechanism between the symptoms of different ‘levels’.
The connection between the levels has not to be immediate. There might even exist a long period of time with no symptoms at all. A patient given a acid-suppressive therapy will not immediately develop pneumonia, if at all. And a patient with recurrent pneumonias discontinuing acid-suppressive therapy will not produce a relapse of his gastritis immediately. It might even be missing.
Especially in atopic disease no symptoms might be seen for decades. Eczematic dermatitis occurs mostly in early childhood for several months or years and asthma might arise at the age of 20 or even later. This connection is still regarded as ‘from exterior to interior’.
According to Hering’s rule suppression would be characterized by the line eczema allergic rhinitis asthma deeper rooted diseases as depression, psychosis (chap. 2.3.h) or ADHD (Simchen 2004). This line must not include all steps. Eczema and depression might follow each other immediately demonstrating a low ability to maintain an equilibrium. An effective therapy would follow the opposite line. When depression becomes better and asthma or eczema arises it is seen as favourable and the process should be supported or, at least, not disturbed. In such a case a homeopathic therapist might leave the eczema untreated for weeks and months, as long as the more inner symptoms (depression or asthma) improve. In treating the skin symptoms he would see the danger of creating a new suppression with a negative impact onto the health of the patient.
Such a view makes no sense for the orthodox physician. But it might be worthwhile to investigate such empirical models, especially as scientific medicine has no theory at all about the interconnectedness of inner processes.
From chronic to acute:
This part of the rule says that when a chronic disease becomes better acute diseases will prevail for a while. This observation of empirical medicine is supported by the current physiological knowledge.
Chronic disease is characterized by a lack of typical body rhythms (Hildebrandt et al 1998: 33). The activation of inner rhythms is accompanied by crises (chap. 5.3.b). These crises can be the initial deterioration (chap. 6.11) of the usual symptom. It might be, as well, a problem unconnected to the initial disease. A typical case in balneology is an abscession of a tooth becoming symptomatic. Of course, this abscession has existed before but through the general activation the inflammatory focus becomes symptomatic.
Furthermore, a lot of chronic diseases are characterized by a type 2 situation (chap. 6.3) with a reduced ability to fight acute bacterial and viral diseases. That is, a lot of pathogen germs are present in the flora but are not attacked. When the relation between Th1 and Th2 cells improves, immune response will improve as well. As a consequence the organism will combat these germs leading to a series of acute infections. Every new infection and every new elimination will change the composition of bacterial and viral flora (Nowak/Sigmund 2004), something that might lead to further acute reactions until a new adaptation is attained. That is, a immune system finding a new balance from a pre-existent type 2 imbalance will mostly lead to acute infections. Empirical observations suggest that this development starts normally several months after the beginning of a therapy. This coincides with the finding of chronomedicine that the reoccurrence and stabilisation of rhythms is a process of months (Hildebrandt 1986: 203-204).
In the social setting of the family it can be assumed that when a deadlock resolves and more resources are available, problems are tackled and solved which had remained untouched for years.
Backwards in time:
This is an often made observation. In the first days or weeks of a therapy old symptoms that have been forgotten reappear. Old wounds might itch, a trauma that happened years before hurts again, an old lumbago becomes symptomatic, etc. This might occur within days and each symptom remains for minutes, hours or days. This process might also be protracted, with the symptoms be present for weeks.
There are different explanations. Based on the hierarchical model from exterior to interior one might assume a reversal of a former suppression. A more pathophysiological explanation would be that there are apoptotic processes (chap. 5.3.a) all over the body that never had been terminated completely maintaining minor inflammations. Such remaining subclinical processes might be the consequence of the immunological imbalance of chronic disease. In finding a better balance the immune system becomes capable to terminate these processes.
From top to bottom:
The observation that a process leads to a better equilibrium when symptoms from the upper part of the body disappear and symptoms in a lower part of the body appear (or from proximal to distal) is not supported by any cybernetic or physiological model. Up to my knowledge there is also no correlated concept in family therapy, either. Interestingly Hippocratic medicine and homeopathy maintain such a relation.