Georg Ivanovas From Autism to Humanism - systems theory in medicine
The most difficult part in the understanding of Hippocratic medicine is the principle of how an individual prognosis can be established. It is difficult because it is incompatible with our current medical paradigm. Modern medicine has knowledge of partial processes and probabilities. An individual prognosis is no issue. However, the practitioner will often give an individual prognosis in his daily work. He might do this out of his experience and will, although not covered by scientific evidence, often be correct. But more often these individual predictions are of poor quality.
It is something special that Hippocratic medicine provides rules for such an individual prognosis. Hippocrates even encouraged the physicians to predict the individual course of disease. “I hold that it is an excellent thing for a physician to practice forecasting. For if he discover and declare unaided by the side of his patient the present, the past and the future, and fill in the gaps in the account given by the sick, he will be the more believed to understand the cases, so that men will confidently entrust themselves to him for treatment” (Progn I; Hippocrates Vol. II: 7). As Hippocrates stressed individual prognosis so much and was known to be an excellent observer there must have been something true in his system.
In systemic psychotherapy the individual prognosis (explaining present, past and future) plays also an important role. If the principles of the family interaction are understood, it is not difficult to explain to the family their ‘game’, how it developed and how it will end. Such predictions are sometimes used as a self-fulfilling prophecy, sometimes to avoid the predicted outcome, sometimes, just as intended by Hippocrates, to develop trust in the therapeutic process.
To be sound, a prediction has to be founded on the principles of control and development. Quite the same can be found in the case of the Hippocratic prognosis. The art of his prognosis is based on a careful examination of all symptoms in their rhythmic and dynamic aspect. For example, Hippocrates differentiates fever according to its rhythm and circadian expression: “Day fevers, night fevers, semitertians, exact tertians, quartans, irregular fevers” (Epidemics I, V; Hippocrates I: 155). “Each of these fevers has its modes, its constitutions and its exacerbations” (Epidemics I, XXV; Hippocrates I: 183). But also all kind of alterations of the face are taken into account (Prognostic II; Hippocrates II: 9). Furthermore, every symptom is related to clear-cut structural principles (Lichtenthaeler: 147).
Basic rules in establishing a diagnosis are: If general signs (fever, weakness) become better and an apostasis occurs it is a good sign. The opposite (an apostasis vanishes and fever occurs) is a bad sign. A metastasis of the process to the lower part of the body are prognostically good (the opposite bad).
“Whenever from pneumonia an abscession takes place to the ears, while gatherings occur in the lower parts and fistula forms, the patient recovers. Judge of such cases in the following way. Expect abscessions of this kind when the fever holds, if the pain have not ceased and the expectoration be not normal, if the stools be not bilious, nor become loose and concocted, if the urine have not a very thick, copious deposit, but be assisted favourably by all the other favourable symptoms. The abscessions occur, some to the lower parts, whenever some of the phlegm appears in the region of the hypochondrium, others to the upper parts, whenever the hypochondrium continues to be soft and painless, and the patient suffers from a temporary shortness of breath which ceases without any manifest cause. Abscessions to the legs in severe and critical pneumonia are all beneficial, but the best are those that occur when the sputum is already changing. For if the swelling and the pain take place at the same time as tlie sputum is turning from yellow to purulent and is being evacuated, the patient is quite certain to recover, and the abscession will very quickly come to an end without pain. Should, however, the sputum be not well evacuated, and the urine do not show a good deposit, there is a danger that the limb will be lamed or else cause much trouble. Should, however, the abscessions disappear without the evacuation of sputum and while the fever lasts, the prognosis is bad, as there is a danger lest the patient become delirious and die. When empyema occurs as the result of pneumonia, older patients are the more likely to die; with other kinds of empyema younger people more easily succumb“ (Prognostic XV///; Hippocrates II: 39-40)
Some of these developments can be explained with the function of the immune system. In a local infection or an abscession the immune system is still able to control the disease. If the local inflammation vanishes and general symptoms appear there is a breakdown of the first line of defence. Bacteria might produce metastases somewhere else or provoke sepsis, such as case VIII from epidemics (Hippocrates I: 233-234).
“The woman suffering from angina who laid sick in the house of Aristion began her complaint with indistinctness of speech. Tongue red, and grew parched.
First day: Shivered, and grew hot.
Third day: Rigor; acute fever; a reddish, hard swelling in the neck, extending to the breast on either side; extremities cold and livid, breathing elevated; drink returned through the nostrils she could not swallow stools and urine ceased.
Fourth day: General exacerbation.
Fifth day: Death.”
But the immune reaction is not enough to explain everything. The Hippocratic method is based on a hierarchical structure in which a teleological process takes place. This process can only be understood by introducing basic notions of general systems theory.
Centralisation: All rhythms of the body are hierarchically organized and not a bundle of unconnected rhythms of single cells and organs (Hildebrandt, 1998: 121). The hierarchy starts from the cellular level of clock genes, integrates all kind of inner and outer influences, such that a stable rhythm emerges.
Goal orientation: The human organism tries to maintain its function in a changing environment. Describing the process of recovery in a teleological way implies that the observed processes, here the inflammation, has to fulfil a task. Under this aspect it is not an accidental series of events caused by a bacterium or a virus. It is a purposeful action in order to re-establish or to maintain an inner balance.
Equifinality: A goal (here the goal of recovery) can be achieved in different ways, depending on the inner state of the system. The course of an inflammation is influenced by many factors such as the quality and quantity of the stimulus, the state of nutrition, the competence of the immune system and others. All this might alter the course. Unpredictable, though, the normal inflammation follows a certain pattern: it starts, achieves a peak and resolves, i.e., inflammation is effective and self limiting. Such cases are described by Hippocrates just with “complete crisis”, or “perfect crisis”. That is, in any kind of disturbence a certain rhythmic structure can be observed where complications might be encountered or overcome. If the time structure is missing, it is a bad sign today mainly associated with chronic disease.
In the light of these principles combined with the assumption that an organism tries to maintain the best equilibrium, what is called adaptation, the Hippocratic prognosis seems to be a meaningful tool.
Striking is that the Hippocratic principles are congruent with the so-called Hering’s Rule of homeopathy (appendix VI). This rule provides an exact structure to judge individual processes. It is also in line with the principles of general systems theory. It is intriguing that with the background of Hering’s rule all Hippocratic cases become simple and intelligible.
That is, empirical medicine of different centuries found a similar way to describe processes and changes in an individual, giving clear instructions if and when an interventions are necessary.