Principles of allostasis : optimal design , predictive regulation , pathophysiology and rational therapeutics . Peter Sterling

Introduction. This chapter compares two alternative models of physiological regulation. The first model, homeostasis (" stability through constancy "), has dominated physiology and medicine since Claude Bernard declared, " All the vital mechanisms...have only one object – to preserve constant the conditions of ... the internal environment ". His dictum has been interpreted literally to mean that the purpose of physiological regulation is to clamp each internal parameter at a " setpoint " by sensing errors and correcting them with negative feedback (Cannon, 1935: Figure 1). Based on this model physicians reason that when a parameter deviates from its setpoint value, some internal mechanism must be broken. Consequently they design therapies to restore the " inappropriate " value to " normal ". The homeostasis model has contributed immeasurably to the theory and practice of scientific medicine, so to criticize it might almost seem absurd. Yet, all scientific models eventually encounter new facts that do not fit, and this is now the case for homeostasis. In physiology, evidence accumulates that parameters are not constant. And their variations, rather than signifying error, are apparently designed to reduce error. In medicine, major diseases now rise in prevalence, such as essential hypertension and type 2 diabetes, whose causes the homeostasis model cannot explain. For in contrast to the hypertension caused by a constricted renal artery and the diabetes caused by immune destruction of insulin-secreting cells, these newer disorders present no obviously defective mechanism. And treating these diseases with drugs to fix low-level mechanisms that are not broken turns out not to work particularly well. The chapter will expand upon each of these points.