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  Making a Medical Diagnosis From the Anthroposophical Point of View
  

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By: Manfred Weckenmann, M.D.
Making a Medical Diagnosis From the Anthroposophical Point of View -- One Way Which Takes Account of Rudolf Steiner's Medical History Questions (Original title: Wie kann eine medizinische Diagnose nach anthroposophischen Gesichts-punkten zustandekommen? Ein Weg unter Beruecksichtigung der Anamnesefragen Rudolf Steiners. Der Merkurstab 1996; 49: 207-13. English by A. R. Meuss, FIL, MTA. Based on a lecture given at the Ottersberg Independent Art Study Center on 6 February 1996.)

Abstract
One approach to diagnosis based on anthroposophical science of the spirit is based on Rudolf Steiner's Medical History Questions (key questions). The answers allow us to draw conclusions as to how powerfully or weakly the higher aspects of the human being are acting. To date, the questions have been validated for 450 patients. It was found that answer patterns indicated powerful or weak activity with more than random frequency. The polarities at the astral (pulse/respiration quotient [P/R Q] of 4) and the I levels (warmth organization) are largely independent of this. An attempt to gain access to the level of the etheric polarity failed.

Introduction
M. Girke had asked me to write a practical summary of our "Pilot Study on R. Steiner's Medical History Questions in Relation to Clinical Syndromes",(13) presenting it under the above title to emphasize the practical aspect.
Why do we need a diagnosis and how far does it go?
In clinical medicine, the purpose of making a diagnosis is to find the treatment. Seeking to find our way to the natural medicine (in its deepest sense) we have to take diagnosis as far as the "door" that opens, or is able to open, the connection between human being and natural process.

Example:
• the astral separates so much from the etheric in a particular syndrome that the etheric goes beyond the astral in the periphery, e.g. with "hayfever". The same process normally happens in Spring in the natural world so we may compare the morbid process with the normal Spring process. The polar opposite to this is seen to be Fall, and natural products of the Fall can stimulate the counter process to a Spring process that has "penetrated too much".(15)

Ideally, the diagnosis goes so deep that it comes to what man and nature originally had in common, out of which the healthy human being developed in one direction and the natural process in the other.

Example:
• in Spring, the vegetative goes beyond the astral in the natural world (the open, light-filled Winter woods grows leafy and full of dark life). A healthy individual maintains his selfhood against this, and the soul awakens (jubilation and joys of Spring). If the process is depolarized, the human being becomes "natural" (Spring tiredness, hayfever).(15) The common origin for man and nature is the "point in evolution" at which man entered into a healthy human respiratory organization on one hand, and plant growth in Spring became the opposite pole. When diagnosis is taken to the "base", we inevitably face the question of how the aspects of the human being relate.
What dangers lurk on this road to spiritual scientific diagnosis?
Not having the spiritual scientific schooling to make a diagnosis in the above-mentioned way, I looked for anything that might aid me. Steiner provided aids, which suggests that he did not expect physicians to be clairvoyant on principle. Steiner frequently said that the path of higher knowledge is not necessarily error-free.

Example:
• if a scientist, able to gather external data, finds some that go against the discoveries made in the science of the spirit, he can and may "rap" the spiritual scientist "over the knuckles".(9) However, the momentary physical condition cannot be established even on the basis of a confirmed spiritual scientific diagnosis. Diagnosis must be on both levels.
There are signatures in the sense-perceptible world that suggest realities
which lie beyond that world, but Steiner only accepts them if confirmed
by supersensible science. Conversely "taking supersensible facts further in one's thoughts" has its dangers.

Example:
• in neurasthenia, the upper forces take hold too strongly of the upper organization before they can mediate themselves to the lower human being. In hysteria, Steiner said, the lower organization was only weakly taken hold of by the upper.(8a) A "thought-out" conclusion: neurasthenia and hysteria are the same in the lower sphere. This is wrong.

Another danger is that of transferring a signature.

Example:
• as the P/R Q is a measure of polarity in the astral body, we may think it is also a signature of polarity in the ether body (hysteria/neurasthenia). This wrong conclusion caused me to go astray until quite recently. Problems also arise with the terms powerful/weak intervention from the higher aspects.
Examples:
• powerful intervention may be thought to relate always to intervention in terms of the upper organization;
• powerful intervention is healthy, weak intervention morbid;
• powerful intervention indicates strength on the part of the higher aspect (in the case of a tumor the powerful intervention of the I splinter shows weakness of the I organization;(8c
• weak intervention is a sign of a below-par organization.(8b)

Symptoms do not tell if they arise directly from the pathology or are part of the polar medicinal illness, like the cough with a tubercular disposition;(8a) nor do they tell if they relate to the primary disease process or are simply a sequel, the nuance varying according to personal disposition or constitution.

Examples:
• trophotropism or ergotropism with orthostatic instability;
• catarrhal symptoms of either the upper respiratory tract or of the gastro-intestinal canal in the same influenza epidemic.
What reliable routes can lead to anthroposophical medical diagnosis?
The surest way to diagnosis is unbiased, comprehensive phenomenology and conscious spiritual scientific insight that may go as deep as intuition. If the latter is not given to us, we still have the former - homeopathy as an honest, modest "protestantism".

If one still wants to go beyond this - not because one finds it unbearable but because one wants to - the following are available:
• one takes the Goethean route;
• one follows one's intuition insofar as one is able to achieve it at one's present stage of development, which generally means more at an unconscious level (great physicians have achieved remarkable results with it);
• one practices typical situations described in the science of the spirit (typical medicines) and asks oneself if such a situation may pertain in the individual case, e.g. migraine;
• one feels one's way into the signatures presented in the science of the spirit seeking to gain confidence in them and leam their limits; in the final instance, we are enabled to practice our own powers of judgment and gain supersensible access.

We sought to take a first step in this direction in our pilot study.(13) Confidence is gained through validation, limits by the possibility to make distinctions. The first question to ask is: which relationships in an organism would be important for diagnosis.
What would be important in spiritual scientific diagnosis?
We took our lead from Steiner,(8b,11) considering the relationship between higher and lower aspects and the question of the polar relationships on the separate levels of the etheric, astral and I organizations. A second step consisted in determining if the polar order on one level permits conclusions to be drawn concerning that on another. Not having direct supersensible access, we used certain signatures. A third step was to look for further valid signatures. The basis of our results is given in earlier papers,(13) and they have since been tested further.(4,14)

Choice of signatures
The relationships between the higher (I, astral body) and lower (ether body, physical body) aspects may be established from the patients' answers. We used Steiner's Medical History Questions for this, in this case called "key" questions.(8b, 11,13a) Depending on the answer, the intervention of the higher aspects in the lower would be either powerful or weak.

At the time, we could not gain true insight into polar relationships on the etheric level. We thought the pulse/respiration quotient might provide this, but this proved to be wrong. Having tested the P/R Q, we can see these results to be the signature for the polarity in the astral body, its decompensation > or < 4 at rest,(10) (for method, see(13a)).

As the I organization comes to expression in the temperature distribution,(6) which is the indicating sign for the day-night rhythm,(2) an I-rhythm(5) that presents in the polarity of ergotropism and trophotropism, we chose ergotropic and trophotropic temperature distribution as an indicator. A good indication is obtained with the question concerning warm or cold extremities.(13a) This temperature distribution shows a relatively dose relationship to the body form,(13,13b)so that warmth is seen to be a force in creating the human form.

Our investigations were made with inpatients at the medical unit of the Carl Unger Clinic. The first study included 166 patients (for method, see13a), the second, not yet published, 176 patients.(14) The scaled raw data were analyzed using the Pearson Product Correlation, with the results statistically assessed.(13a) The first step was to test the signatures for their validity.

Are signatures certain to be true indicators?
This is something we cannot assess in a supersensible context. Steiner did, however, give a number of key questions that relate in a similar way to the same factor: higher aspects intervening powerfully or weakly in the lower aspects of the human being. It was to be expected, therefore, that the totality of answers given by individual patients would reflect weak or powerful intervention at more than a random level.

We were able to confirm this in principle by two different methods,(13a) the exception being the key symptom, vertigo. Steiner saw vertigo due to external mechanical movement as a key sign of powerful intervention, but what kind of mechanics?

First, we assessed vertigo in a differentiated way for rotating/dancing, bending down, coming upright, and looking down into depths. All these types of vertigo showed positive correlation with one another (r = +0.24 -+0.52 sig-h-sig.). All of them might be used as key symptoms. Contrary to Steiner's statement, these correlated with key answers for weak intervention, except that in 36% of cases correlation was with answers for powerful intervention.(13a) We therefore took courage and converted the signature for all four types of vertigo together into weak intervention.

Steiner emphasized that elimination disorders were also keys,(8b) though he did not say which disorders related to powerful or weak intervention. We examined the relationship to the other key answers and found a marked relationship to weak intervention for chronic constipation.(13d) Finally it was also possible to establish some relationship to some key answers for sweating in general, indicating weak intervention.(14) We have not so far looked at relationship to urinary and sexual eliminations.

Kroez(4,13a) was able to confirm the above in principle in a study including 108 patients with and without breast cancer.

To date, therefore, the following signatures have been established with 450 patients:

Key questions
Intervention of higher aspects in lower aspects: weak/powerful
sleeping badly: yes/occasionally/no
dreaming: yes/very rarely/no
need to taste: sweet/salty
effort to do things (indolence): yes/no
sightedness: shortsighted/longsighted
vertigo: yes/no
bowel movements: chronic constipation/normal
tendency to sweat: yes/no

With equal levels of significance (p = 0.000), we found(13,14) that individuals produce many mixed answer patterns, but less so than one would expect at random; patterns tended to show a bias for powerful or weak intervention.(13a)
Questions still to be considered are: if individual questions have specific significance and if an individual answer pattern therefore permits differential diagnosis. For the moment, only trends can be derived from individual answer patterns.

Validation of the P/R Q as an indicator for dominance of a radiant astral pole intervening more powerfully in the blood (P/R Q > 4) or a rounding-off astral pole relating more to the nerves (P/R Q < 4) was by means of the signature: increased anxiety (P/R Q elevated) v. not knowing what one wants (P/R Q reduced),1311 for which Stich obtained empirical data.(12)

The relationship between day/night rhythm and warmth organization is general medical knowledge,(1,2,3b) as is its extreme development in ergo-tropism and trophotropism.(15) The signature "extremities tending to be cold or warm" proves to be a necessary one; it has proved its value in my practice. In addition, ergotropic patients tend to be slender, trophotropic patients more full-bodied, which is significant.(3'13b). A second step was to use this repertoire of signatures to determine correlative relationships between individual levels interindividually.

What relationships between functional levels can be determined using the signatures?
Powerful/weak intervention only showed consistent correlation with the ergotropism/trophotropism pole in the vertigo symptom. Patients tending to vertigo were more ergotropic, those without vertigo more trophotropic.(13a) This had been confirmed on further investigation but required further study.

The P/R Q criterion was remarkably unrelated to all other levels examined. We therefore do not see it as a measure for ergrotrophism/tropho-tropism.(1) It appears, therefore, that the three levels examined are relatively independent of each other. It is not possible to draw conclusions as to the situation on one level by considering another. The levels require separate assessment and differentiated reference in diagnoses based on the science of the spirit.

Further investigations will be needed in this area.

Examples:
• what does weak/powerful intervention mean for differentiation between astral body and I?
• what does weak/powerful intervention mean when ergotropism is dominant, and when trophotropism is dominant?

We now have to consider the third of the above questions, which concerns further signatures.
Can other reliable signatures be found?
One of the most consistent signatures proved to be the polarity between "depressed" and "calm" basic mood. A depressed mood associated strongly with weak intervention, a calm mood with powerful intervention. This has been checked and confirmed(13c,14) Women are more likely to show weak intervention and a higher P/R Q, men the opposite.136 Generally speaking the degree of intervention did not show age relation.1311 However, patients with metabolic diseases (type II diabetes, adiposity, degenerative skeletal disease, chronic liver/gallbladder/kidney disease) tended to show powerful intervention; patients with more asthenic conditions (exhaustion, autonomic instability, uncomplicated unstable hypertension, dyspepsia) more weak intervention.(13b) The inclusion of unstable hypertension among asthenic conditions may seem strange, yet it was found that patients with primary unstable hypertension without complications tended to show weak intervention, which became powerful when complications developed (transversal examination).

What measures should be taken?
To establish the spiritual scientific diagnosis for chronic conditions, I have made it a habit to determine the following:
• the eight key answers
• the question of cold or warm extremities
• the P/R Q with the patient lying down.

The questions are perfectly sound psychologically, yet they permit a profound spiritual scientific diagnosis. Determination of P/R Q in the office is relatively simple. When the patient has been lying down for a short time it is often sufficient to determine pulse and respiration rates — counted by palpation and visually at the same time - over a period of 1 or 2 minutes. If in doubt, repeat at the next visit. It is sufficient to establish if the P/R Q is in median range (3.5—5) or above or below. Translating this into treatment requires a further step, which it is not yet possible to discuss here.

Conclusion
The whole procedure may seem mechanical to some or smack of spiritualism (neo-Kantian). It is strictly phenomenological (not even involving depth psychology); it does not postulate supersensible mechanisms, nor does it offer analogies of sense-perceptible or supersensible images to provide illumination.

The relationship between sense-perceptible and supersensible was "investigated" in spiritual science by Rudolf Steiner and "checked" indicatively as regards sensory perception. The method does not dispense with the need for personal effort to gain spiritual-scientific insight, but I can test the probability of first, tentative results by comparing the intuitive observations on the patient with my phenomenological observations and gain certainty in forming an opinion. Steiner outlined this route for us," as also shown in the paper on his Medical History Questions.(13f)

Access to the level where the polarity between hysteria and neurasthenia is to be found still needs to be worked out.

The method is still not error free for phenomena do not always allow us to draw absolutely certain conclusions to a particular spiritual state of affairs. Phenomena are "multiple in origin". It therefore needs supersensible confirmation in the individual case as to where the origin lies. Respect for the "multiple origin" will help us not to abuse such a method for the laws of the spiritual world are hidden from us for the time being.(7)

References
1 Hildebrandt G. Therapeutische Physiologie - Grundlagen der Kurortbehandlung. In Ame-lung W, Hildebrandt G (ed.) Balneohgie und medizinische Klimatohgie Band I. Berlin: Springer 1985.
2 Hildebrandt G. Chronobiologische Aspekte der Thermoregulation des Menschen. Ans dem Institut flier Kurmedizinische Forschung, Bad Wildungen 1985; 3:131-49.
3 Hildebrandt G. Ishag George B. Untersuchungen ueber die Bedeutung anainnestischer Fra-gen fuer die Bestimmung vegetativer Reaktionstypen. Z angew Bieder- und Klimaheilk 1973; 20:
237-73,365-85.
4 Kroez M. Praemorbider Koerpermassindex, Vegetativum und konstitutionelle Aspekte sowie PerscenlichkeitsmerkmalebeiMamrnacarcmom-Patientmnen. Inaug. Diss. vorbereitet.
5 Steiner R. Anthroposophical Knowledge of Man (in GA 107) lecture of 21 December 1908. Manuscript translation C:A at Rudolf Steiner House Library, London.
6 Steiner R. The Bridge Between Universal Spirituality and the Physical Constitution of Man (in GA 202) lecture of 17 Dec. 1920. Tr. D. Osmond. New York: Anthroposophic Press 1958.
7 Steiner R. Wonders of the World (GA 129) lecture of 22 Aug. 1911. Trs. D. Lenn and 0. Barfield. London: Rudolf Steiner Press 1988.
8 Steiner R. Spiritual Science and Medicine (GA 312). Tr. not known. London: Rudolf Steiner Press 1975.
a) Lecture of 22 March 1920.
b) Lecture of 25 March 1920.
c) Lecture of 3 Apr. 1920.
9 Steiner R. Naturbeobachtung, Mathematik, wissenschaftliches Experiment und Erkenntnisergebnisse vom Gesichtspunkte der Anthroposaphie (GA 324) Vortrag vom 23. 3. 1921. Not translated into English.
10 Steiner R. Health and Illness vols. I and H (GA 348) lecture of 13 Jan. 1923. Tr. M. St. Goar. New York: Anthroposophic Press 1981 & 1983.
11 Steiner R, Wegman I. Fundamentals of Therapy (GA 27) ch. 19, 1st case. Tr. E. Frommer, J.Josephson. London: Rudolf Steiner Press 1983.
12 Stich P. Pulsfrequenz, Atemfrequenz sowie Puls-Atem-Quotent und Persoenlichkeitsmerk-male. Inaug.-Diss. Marburg/L. 1986.
13 Weckenmann M, et al. Pilotstudie ueber die Anamnesefragen R. Steiners und ihre Bezie-hungen zu klinischen Bildem. Der Merkurstab 1995; a) 48: Teil n 161-76 [English translation:
"Pilot Study on R. Steiner's Medical History Questions in Relation to Clinical Syndromes". JAM 1995; 12(4)4-23; tr. C. v. Amim]; b) Teil m 236-50; c) Teil IV 323-34; d) Teil V 417-424; e) Teil VI 515-23; 1996 49: Teil Vu 23-28.
14 Weckenmann M. Die Anamnesefragen R. Steiners in Beziehung zu weiteren klinischen Merk-malen. Veroeffentlichung vorbereitet (due for publication).
15 Weckenmann M. Ueber die Behandlung von Heuschnupfen und




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