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The Cancer Journal - Volume 6, Number 5 (September-October 1993)

editorial


How to understand a disease?



"It is easier to cure a patient than really to know what his disease is", said Ludwick Fleck, the founder of the philosophy of modern medicine (1, 2). According to Fleck, diseases do not exist in nature but are constructed by physicians for didactic reasons. Cognition of a disease is achieved through the senses, intuitively and by reasoning. The first two served the physician until the advent of modern medicine, and are gradually being abandoned. Sophisticated imaging techniques and laboratory tests are replacing our senses, and intuition is yielding to reasoning. It seems as if modern technology will soon transform medicine into an exact science, yet medicine is still unprepared for this transition. It lacks a methodology for dealing with the information generated by laboratory instruments, and the clinician is flooded with data which he barely assimilates. The time has come to explore ways for transforming medicine into a science. By medical science we mean the science of clinical medicine, and not the basic medical sciences, e.g., pathology and microbiology.

Phenomenological studies by physical sciences are regarded as systems with many interacting components. For the physicist, the understanding a physical system means that he can account for all factors involved in it. This approach fails in medical systems which are extremely complex and it is impossible to account for all factors operating in a disease. Disease complexity has to therefore be considered when formulating a framework for medical science.

In order to study a physical system the physicist first defines the system's units, or atoms, that serve for its reconstruction. In medical systems, on the other hand, such a unit does not exist. Take for instance a cell. There is more in a tissue than accounted for by the cells which make it up. The tissue is more that the sum of its cells. While physical systems are generally the sum of their elements, medical systems are more than the sum of their elements, which has to be considered when defining the medical atom.

The organism may be structured into hierarchies, e.g., organism => organ => tissue => cell. Each hierarchy will be also defined as a hierarchy-atom of the hierarchy above it. For instance, when viewed from the hierarchy above, the cell-atom appears as indivisible unit, yet from the viewpoint of the hierarchy below it encompasses the universe of subcellular organelles. According to A. Koestler: "The members of a hierarchy, like the Roman god Janus, all have two faces looking in opposite directions, the face turned toward the subordinate levels is that of a self-contained whole; the face turned upward toward the apex that of a dependent part (3). Koestler called this unit, the holon.

In order to apply the holon concept to clinical medicine we have to define precisely what is meant here by Disease and Diagnosis. The organism is a medical system which exists in different states, e.g., health and disease, and diagnosis is a method for distinguishing between them. These definitions, although intuitively plausible, are too vague and will therefore be defined as follows: a disease is a list of statements which describe all that is known about its nature. Not all statements about a disease are required for curing a patient. Let us call the set of statements which are necessary for curing a disease as Diagnosis. The advantage of this definition is that it can be tested. A diagnosis is tested by its outcome. If the patient is cured the diagnosis was correct, if not, it was wrong. Take for instance iron deficiency anemia. Statements, e.g., iron turnover, oncogene status of bone marrow cells and tachycardia, describe the disease, yet not all of them are essential for diagnosis. Diagnosis consists of statements, e.g., pallor, weakness, tachycardia, low hematocrit and iron pills. We may even narrow down the definition of diagnosis; it is the smallest set of statements with the aid of which the patient is cured. A chronic disease is a disease without diagnosis since it is impossible to formulate any statement for curing the patient.

In order to arrive at a diagnosis we first define the holons involved in a disease. For the diagnosis of iron deficiency anemia the organism itself may serve as holon, and clinical manifestations of the anemia will be the necessary statements of the diagnosis set. Diagnosis will be tested by the response of the patient to iron treatment. If he does not respond, the diagnosis set has to be defined anew and tested again. Thus in spite of the fact that medical systems are more complex than physical, they can be simplified by the present method. Clinical medicine is a science of complex systems. From the present point of view, Fleck's assertion that it is "easier to cure a patient than to know what his disease is", is wrong since by curing the patient we actually understand the disease.

The history of medicine is a continuous search for new holons and ways to incorporate them into the diagnosis set. The evolution of medicine involves the exploration of deeper and deeper holons. Initially the diagnosis of iron deficiency anemia was based on the organism-holon. Light microscopy introduced the cell-holon, then came the discovery of the sub-cellular holon of cell organelles and so on. In spite of technological development, diagnosis of many disease is still based on the organism-holon. The main task of medical science is to select the appropriate holons that are to be included in the diagnosis set.

The new interpretation of medical concepts, e.g., disease and diagnosis, is necessary for transforming clinical medicine into a scientific discipline. Following this transition, medical science will also be endowed with its own mathematics, known as Chaos (4-7). Concepts, e.g., the "strange attractor" that has the properties of Koestler's holon are appropriate for describing disease and diagnosis with the rigor of physics.

All this also applies for understanding cancer, a chronic disease without diagnosis. The present approach is useful for evaluating cancer theories, e.g., somatic mutation, growth factors, oncogenes, or immunity. Although important for describing cancer as a disease, they cannot be included in its diagnosis since none contributes to cancer cure.

G. Zajicek
e-mail: Gershom@md2.huji.ac.il

REFERENCES

1. Lowi I. The immunological construction of the self. In: "Organism and the Origins of the Self". Tauber AI ed. Kluwer Academic Publishers Norwell USA, p. 43-71, 1991.
2. Zajicek G. Ludwick Fleck: founder of the philosophy of modern medicine. The Cancer J 5, 304-305, 1992.
3. Metaphysics and cancer. From Gaia to Selfish Genes. Barlow C. Editor, The MIT Press Cambridge MA, 87-1000, 1991.
4. Gleick J. Chaos. Making a New Science. Viking 1987.
5. Zajicek G. Meta-analysis and chaos. The Cancer J 4, 152, 1991.
6. Zajicek G. Chaos and biology. Meth Inform Med 30, 1-3, 1991.
7. Zajicek G. Artificial life. Meth Inform Med 31, 167-168, 1992.


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