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  The Challenge of Diagnosis
  

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By: Ira Cantor, M.D.
It is quite conceivable that someone might think it useless to adopt the methods of empirical thought in physiology or biology. What need is there for any specialized branch of science, he might ask. One develops spiritual sight, looks into the spiritual world, arrives at a conception of man - of the being of man in health and disease - and then it is possible to found a kind of spiritualized medicine. As a matter of fact, that is just the kind of thing many people do, but it leads nowhere. They abuse empirical medicine; but they are, after all, abusing something which they do not understand in the very least. There can be no question of writing off empirical science as worthless and taking refuge in a spiritualized science brought down from the clouds. That is quite the wrong attitude to adopt.

Now, it must be remembered that spiritual-scientific investigation does not lead to the same things that can be examined under the microscope. If anyone tries to pretend that, with the methods of Spiritual Science, he has found exactly the same things as he finds under a microscope, he may safely be summed up as a charlatan. The results of modem empirical investigation are there and must be reckoned with. Those who seriously pursue Spiritual Science must concern themselves with the phenomena of the world in the sense of ordinary empiricism. From Spiritual Science we discover certain guiding lines for empirical research, certain ruling principles.
-- Anthroposophical Approach to Medicine, Rudolf Steiner Lecture I (26 October 1922)

Anthroposophical medicine offers an abundance of new perspectives on the sick human being and how we, as physicians, can deepen the traditional diagnosis. We find, however, that the tools we need to refine and make our diagnoses more exact are often lacking.

The initial and most important tool that we possess is the patient's history and physical exam, as expanded by anthroposophical insight. Cramps can be the manifestation of an exaggerated activity of the astral body, for example. Certain physiognomic qualities can point us to specific organ diagnoses. An excessively sculptured and rigid quality or a continually-changeable, sanguine physiognomy suggests a lung or kidney typology respectively. Experienced anthroposophical physicians and therapists can expand these examples considerably viz how to recognize the four members, how to recognize planetary types, etc. Despite these insights, certain dilemmas in the diagnostic process are frequently met, and we find ourselves coming up against a wall which we need to go beyond in order to help our patients.

The first dilemma is the hypothetical nature of our diagnoses. When we diagnose a "liver" problem, how do we know we are correct? From an epistemological perspective, we stand on very shaky ground. Our process is that, through a Goethean approach, we describe certain qualities of an organ. In the case of the liver, we speak especially of its fluid qualities, of its central role in the metabolic system, of its enormous regenerative and "plant-like" attributes. When we see problems with a patient, such as an excessive phlegmatic constitution, a "watery" constitution, or a difficulty of the astral body and ego to incarnate because of a stagnant, watery physiology that isn't enlivened, we diagnose a "liver" problem. But this is circular reasoning. It is scientifically and philosophically untenable. We need to ground our ideas about the liver in verifiable facts in order to step out of this circle of reasoning. If our "liver" treatment doesn't work, we can then figure out why.

A second dilemma follows directly from the first. Let's say that it is, indeed, true that our diagnosis is correct, that this is a "liver" problem. The liver is an organ with many functions - carbohydrate metabolism, detoxification, protein synthesis, and warmth production are only some examples. To say that the liver is the central organ of metabolism, of the fluid organism, of the etheric, is not specific enough. How do we further differentiate and make more exact the specific kind of liver problem that the patient has? This is important, particularly in how it affects our therapy. What makes us choose between Fragaria/Vitis, Taraxacum, Carduus Marianus or Magnesium7 All are liver treatments, but each is directed at a different aspect of the liver's function. Could it be that Carduus Marianus is more specifically indicated in problems related to detoxification, while Fragaria/Vitis directs its activity more to the sugar/glycogen metabolism which underlies the liver's functional/etheric capacities?

The dilemma of further differentiation also appears when we make a diagnosis of exaggerated astral body activity in, for instance, dysmennorrhea or spastic colon. Is the problem with the astral body itself, or is it because the ego can't control it, or is the protective cushion that the etheric body provides lacking? These examples highlight some of the dilemmas facing us in our daily clinical practices. In my opinion, they have even greater significance than this, and unless we cross these barriers, our ability to develop anthroposophical medicine further is hindered. We remain in the realm of vague generalizations and unverified hypotheses (as helpful and interesting as these may be). How do we cross these barriers and how do we make our diagnosis more exact? How do we verify that our Goethean and anthroposophical approaches are true?

One obvious, but very difficult, method lies in developing our higher organs of perception where we perceive directly the supersensible bodies. Another method, more indirect, is what some physicians are developing in connection with specific eurythmy movements around parts of the patient's body, noting the changes in muscle tension, etc. Working with massage therapists or recognizing 'reflexology' patterns can also be helpful in this regard. A third area concerns the exponential growth and knowledge of the physiology of living organisms - what is known in some circles as "functional medicine," contrasting it with "static" or "anatomical" medicine. Steiner repeatedly spoke about how we must know things in their living and changing physiological context. What is different today is that we have developed methods to describe this living environment. From an anthroposophical perspective, these descriptions are like footprints of the etheric, the astral, the ego.

Recently, there was an article by Witsenberg and Laceulle in the Journal of Anthroposophical Medicine (Vol. 10, No. 3, 1993) entitled, "Hypertension." They describe two types of hypertensive patient: a pale type and a ruddy type. These types are described as attributable to excessive nerve sense system influence and excessive metabolic system influence respectively. The authors describe various signs and symptoms whereby these types can be differentiated. They caution, however, that: "since not everyone belongs to a clearly-defined type, it can be very difficult in practice to classify a patient along these lines."

Soon after reading this article, I came across a discussion wherein a prominent specialist in hypertension, John Laragh, differentiates hypertensive patients by the level of their renin: high, medium and low (Kidney International Vol. 44 1993). Renin is a hormone produced by the kidneys which has the eventual physiological result of causing vasoconstriction. When it is produced in excessive amounts, its clinical picture correlates very closely with the "pale, nerve sense system" hypertension. The other extreme is the low-renin state, which is basically a high-volume physiological condition. In a general way, this correlates with the "ruddy" or excessive metabolic limb system type. Both the Witsenberg/Laceulle and Laragh approaches have valuable contributions to make.

An advancement and refinement in anthroposophical diagnosis would occur by bringing these two approaches together. This would help us see if our phenomenological observations were correct. It would also help us in evaluating our therapy. Laragh, for instance, notes that high-renin states are associated with a great increase in ischemic events, which can be seen as related to an increasing sclerotic process. If, with our anthroposophical treatment, we note a decrease in plasma renin, even as the blood pressure only slowly changes, we would know we were being successful. As an aside, Laragh has noted that low-renin hypertension has a much lower incidence of ischemic events - even with identical blood pressure levels — than those patients with high-renin hypertension.

This correlates with the anthroposophical view that the latter illnesses are due to a preponderance of nerve sense, catabolic, sclerotic influences. In selected patients, I have tried to clinically predict what their renin levels would be. The matching of the phenomenological clinical picture with the laboratory parameters has often been wrong but has helped deepen and refine my understanding of both aspects, m anthroposophical science, we need to make an hypothesis and then, with future observations, refine the original hypothesis.

Another area where help can be gathered is in gastrointestinal and liver physiology. The GI tract and liver are intimately related (from embryological, anatomical and physiological perspectives). In clinical practice, we see many patients with problems in these areas. Examples of such problems include chronic fatigue syndrome, food sensitivities, and autoimmune disorders. The GI tract forms our greatest interface with the outside world. If our ability to deal adequately with this world of food and GI flora is compromised, numerous clinical consequences result, all with the common denominator of dealing with a foreign substance (food) or organism (bacterial, fungal or protozoal) within our body. This provokes a wide range of inflammatory, allergic and toxic reactions and can lead to a spectrum of symptoms including fatigue, myalgias, rashes, confusion, diarrhea, etc.

When confronted with these patients, my experience has been that they often present the anthroposophical picture of a "liver" patient. Some patients will respond remarkably well to liver treatment with medicines such as Taraxacum, Fragaria/Vitis, etc. There are others who respond only partially or not at all. Why?

The GI tract and liver function as a unified physiological system when looked at from a particular perspective. If our intestinal system is completely healthy, including its digestive and absorptive functions and maintains a proper symbiotic balance of flora, then it presents the liver with no added burdens regarding detoxification and further metabolism. However, if there is a disturbance of any of these functions in the GI tract, the liver is presented with an excessive burden which can compromise its healthy function.

Therefore, we must pinpoint where the problem lies. Tools to accomplish this include the intestinal permeability tests, small bowel overgrowth breath tests, comprehensive digestive stool analysis, and the liver detoxification tests - all available from, among other places. Great Smokies Laboratory in North Carolina.

The stool analysis evaluates the digestive functions, the overgrowth of various organisms such as yeast, various protozoa, and the "balance" between normal bacterial inhabitants of the intestine such as £. Coli, Lactobacilli, Klebsiella, and Pseudomonas. It gives the picture of the "living environment" of the gut and often portrays a picture of dysbiosis, "disordered living ecology."

In the intestine, we have a true physiological/functional situation which contains an enormous foreign "etheric" vitality.

The permeability test measures if our barrier function between self and non-self is intact.

Liver detoxification tests evaluate the liver's ability to process and detoxify substances. It is a window on the liver's functional state. This is in stark contrast to the so-called liver function tests, which don't measure function at all but, rather, the results of an anatomical disruption of the liver cell which then spills various enzymes into the blood stream.

A final example is the refined biochemistry of vitamins, trace elements, amino acids, and minerals that is now becoming widely available. One example is in the realm of cardiovascular disease prevention. Two areas have recently become widely know in this regard. The first involves free radical/ antioxidant biochemistry. Steiner spoke of the differentiation of anabolic and catabolic forces. Oxygen, while intimately related to life, is actually more involved with energy production and, ultimately, a breakdown (catabolism) of substances. It is a very toxic substance. This is reflected in the free radicals generated by oxidation. These free radicals are a footprint of this catabolic activity. Numerous antioxidant substances (including vitamins E and C, beta carotene, and the wealth of bioflavanoids found in the plant kingdom) protect us against these toxic products. A second area involves amino acid metabolism which can lead to an accumulation of a substance called homo-cysteine. Adequate intake and usage of vitamins B6 and B12, as well as Folk acid, prevents this accumulation. From a pharmacotherapeutic perspective, numerous natural medicines such as Cratageus, Primula and Cardiodoron, as well as biodynamic foods, could be looked at from this angle. Levels could be measured and, equally important to the quantitative aspect, their ability to work together in protecting against the catabolic processes could be investigated.

Anthroposophical medicine presents us with an unfinished picture. Steiner himself remarked that he could only give indications and that the details needed to be worked out. Some of the details are now becoming known. They must be developed further and enriched through understanding their importance and place, which Anthroposophy can do. Any science progresses by testing its hypotheses, by proving or disproving them, and moving orr to a further stage of understanding. As anthroposophical physicians, we must have the courage and insight to test further our collective and individual approaches. We must discover what we mean when we say "liver type," when we speak of an "hysterical constitution," when we talk about a "weak etheric." Two cases are presented to illustrate some of the issues that have been raised:

Case I:
Mr. K.E. is a 47-year old, white male with a long history of asthma since childhood. Although allergy testing revealed atopy, allergy shots were not helpful. When the patient was first seen, he was using bronchodilators 4-12 times daily, with occasional oral steroid use. Upper respiratory infections were a common exacerbating factor. He noted that antibiotics led to a fungal groin rash.

Review of systems was important regarding irregular bowel movements and epigastric distress. He also had acne, which showed questionable improvement with acidophilus supplements. His sleep pattern revealed frequent waking and excessive snoring. Psychologically, he discussed a tendency to repress feelings of anger. His family history was significant for a brother with both psoriasis and inflammatory bowel disease.

On examination, the patient appeared very anxious with an exaggerated chest (versus abdominal) breathing pattern. His face was red, his skin warm, but he had cold feet. Lungs revealed mild wheezing.

The initial anthroposophical member diagnosis showed exaggerated astral activity (asthma, anxiety, frequent waking, chest breathing) as well as a disordered warmth/metabolic organism (acne, red face, irregular warmth). His history suggested a digestive component, a propensity to fungal infections, and wide-ranging sensitivities.

When someone has increased astral activity, it means that their sensitivity and overall reactivity are exaggerated. The questions to ask are: (1) what is the person reacting to and (2) why is he reacting in an extreme manner? We have various borders where we meet the outside world: nerve sense system, skin, respiratory system, digestive system. By far the greatest meeting with foreign substances occurs in the digestive system. We also react most strongly in the sense of inflammation in our GI tract. Digestion can actually be understood as a modified, controlled inflammatory process.

After initial treatment stabilization with both conventional (Serevent and Aerobid) and anthroposophical (Chamomilla Cupro Culto and Pneumonium LA) medication, certain investigations aimed particularly at the GI tract were performed.

He had a comprehensive digestive stool analysis, which revealed some mildly abnormal metabolic markers (increased pH and disordered short-chain fatty acid pattern) as well as a greatly increased amount of Candida Albicans (4+). He also had an intestinal permeability test, which revealed greatly increased permeability to both Lactulose and Mannitol (2-3x the upper limit of normal).

These two tests revealed that the GI border between self and non-self was greatly disturbed and that there was a great abundance of foreign life (etheric) in the guise of Candida Albicans within his GI tract. The abnormal intestinal permeability allows the entry of this foreign life into the bloodstream, into the area where only "self" should be. His organism naturally reacts, with his higher members, in inflammation directed against this foreign presence. This contributes greatly to his symptoms.

Treatment was, therefore, directed at the GI dysbiosis with various bitters, including Gentian Stomach Tonic and Grapefruit Seed Extract. Bitters enables the higher members to incarnate more strongly within the GI tract in order to overcome the abnormal foreign etheric. Various other treatments followed with continuing, substantial improvement. These treatments included regular intravenous injections with Magnesium, B vitamins and Lobelia comp. He also received antifungal treatment with Nystatin. A repeated intestinal permeability test showed the Lactulose and Mannitol absorption to be within the normal range, indicating that this border had been strengthened.

Case II:
Mrs. K.F. is a 35-year old, white female with a past history of bulimia, alcoholism, and cigarette abuse. Her bulimia and substance abuse stopped three years before being seen by myself. Two years before being seen, she began having digestive problems and developed secondary amenorrhea. She noted increased gas, indigestion, and alternating diarrhea with constipation. She noted a great amount of undigested food in her stool. Her conventional workup was unremarkable.

On her own, she did an elimination diet and found allergic GI reactions to soy, wheat, dairy, peanuts, and tomatoes. She noted a 50% improvement with elimination of these foods. Of importance in her history, she had not been on antibiotics since she was a child.

She went to a local gastroenterologist whom she persuaded to order a comprehensive digestive stool analysis. This was mildly abnormal, showing evidence of mild malabsorption. She had a very low amount of E. Coli, normally a beneficial bowel commensal. There were no parasites nor yeast noted. The gastroenterologist suggested pancreatic enzymes, which actually worsened her situation. The diagnosis by this physician was irritable bowel syndrome.

When examined by myself, her appearance and exam were unremarkable.

Her story suggested longstanding nutritional problems and substance abuse in the past (weak nutritional/etheric processes), which might have a relationship to an inability to digest and assimilate numerous foods (amenorrhea, bowel malabsorption), as well as an over-reactivity (astral) to numerous food substances. In the spiritual/psychological realm, she had made enormous progress in overcoming her previous problems and appeared relatively normal.

Workup included B12/folate levels, a chem screen as well as a mineral/ trace element study (from Doctors Data in Illinois). The routine tests were normal; however, the trace element study showed all the minerals and trace elements to be 1-2 standard deviations below the mean (though most still in the low normal range). This suggested a general pattern of malabsorption.

She began treatment with Gentian Tonic, Carbo betulae Comp, and Digestodoron. She was also restarted on a more complete elimination diet. These measures led to a significant improvement.

Meanwhile, the patient had a 24-hour urine amino acid profile done. A few words should be said about this test. Amino acids are central in almost all metabolic processes in the body. In addition, their metabolism involves many trace elements, minerals, and vitamins. Therefore, a broad and often specific picture of metabolism can be obtained. This often gives indications of various problems in areas such as GI neuroendocrine, allergic, and assimilative physiology. Though the correction of these abnormalities with supplementation can be important, equally important is the clarification of the physiological and metabolic situation.

The patient's amino acid profile was remarkable in the following ways:
the group of sulfur-containing amino acids is very important regarding allergic/toxic reactions. These include methionine, cysteine, and cystine and are necessary for the formation of the antioxidant enzyme, Glutathione.

From an anfhroposophical perspective, it is interesting in its relationship to sulfur and selenium. Sulfur is a classic toxic substance, as we know so well from the pollution produced in the industrial world. Anthroposophically seen, it is intimately related to the metabolic system and is used in situations of sluggish metabolism, of smoldering, chronic inflammatory digestive states. The sulfur amino acids are directly connected to these clinical situations and are critical to detoxification, especially in the liver. She showed a gross deficiency of these amino acids. This suggested that the liver's detoxification processes had been overwhelmed in the past and were no longer adequate. Also of interest on her amino acid results was a difficulty in properly metabolizing foods containing methionine. These include many protein foods, but especially sulfur-containing foods such as onion, cabbage and mustard families.

An additional test performed was a breath test evaluation for small intestinal bacterial overgrowth. If the small intestine, which is normally sterile, has an excessive content of microorganisms (foreign efheric) and the patient is given Lactulose, these organisms ferment the sugar and produce excessive gases, especially hydrogen and methane. These are then measured in breath samples. The patient's breath test showed a very severe overgrowth.

With the above-mentioned treatment, supplementation of the various mineral and acid deficiencies, as well as a decreased intake of sulfur-contain-ing foods, the patient unproved dramatically and was able to tolerate many more foods. Her small bowel overgrowth was being treated with Bismuth.

Conclusion
The above cases illustrate the struggle to find ways to help patients who have very complicated medical problems. It also reflects my personal interest in integrating various creative medical streams and my belief and practice that anthroposophical medicine is an inclusive, not alternative, medical approach. For many decades, the conventional (allopathic) approach was, indeed, antithetical to the anthroposophical approach. In many ways, it still remains so. However, I find that there's a growing and exciting area of medical science that is substantiating and clarifying many of the basic ideas that anthroposophical medical science has been speaking about for years. Some people might find what has been presented here to be too materialistic. My reply is that the manifestations of illness usually show themselves in the physical and etheric bodies. It is the physician's task, challenge and burden to delve into these realms. The danger is that he will be entangled by Ahrimanic influences. An equal danger is that we may not really penetrate these realms. Unpenetrated matter cannot be redeemed, cannot be resurrected.

It's a universal experience of physicians that they wish to help the patients but often do not possess the knowledge to do so. Their "will to heal" is paralyzed. Knowledge and will go hand in hand.





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