Diabetes mellitus from the Perspective of Anthroposophical Medicine
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By: Matthias Girke
Original title: Diabetes mellitus und Anthroposophische Medizin. Der Merkurstab
2002; 55(Sonderheft-2):4-29.
DOI: https://doi.org/10.14271/DMS-18215-DE
Translation by Peter Luborsky
This translation
is published with the kind permission of the journal Der Merkurstab.
Abstract
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On the background of the three-fold human organism, type 1 and type 2 diabetes mellitus appear as a polarity. In type 1 diabetes action of the nerve-sense system is dominant. In type 2 diabetes action of the will in the metabolic-limb system is restricted. In terms of the human biography, type 1 diabetes appears linked with insufficient incarnation of the soul and spiritual being, type 2 diabetes with premature separation and excarnation.
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Conventional therapy focuses on what can be measured and regulated, i.e. the glucose level. In this way it addresses the physical plane but fails to address the soul and spirit aspects of the illness—the disease process itself. Through its perspective on disease, anthroposophical medicine is able to develop therapeutic aims and concepts that go beyond regulation.
Key Words
Diabetes mellitus type 1 and type 2, Insulin, Insulin resistance, Diabetic nephropathy, Diabetic retinopathy, Autonomic diabetic neuropathy, Polyneuropathy, Diabetic foot syndrome, Rosemary, Mistletoe
Introduction
In diabetology the therapeutic approach has focused on regulating blood sugar to within normal levels, and with commendable results: A disease known for over 2,000 years can now be effectively managed and regulated. The underlying pathology is understood as a disorder of biochemical and—increasingly—molecular biological processes. Yet the deeper question remains as insistent as ever: How do the objective findings of science relate to the whole being of man, embracing not only a physical form but also soul and spiritual dimensions? In this sense the approach of causal analysis needs to be broadened. The life of those suffering from disease is lived on these multiple levels at every instant; and when illness so deeply impinges on their lives and biographies, the above question is alive in them whether or not they express it in words. Medicine must ask itself whether pursuing this question is “merely” a service to the patient's subjective sense of well-being or if it might not lead to new paths in the therapy of diabetes. Will our therapeutic task regarding diabetes mellitus be accomplished when with our growing arsenal of therapeutic tools we succeed in producing glucose profiles matching the “healthy norm”? The answer is clearly “no.” The actual disease process remains untouched by such medication. We have merely gained control over consequences of the illness and thus reduced the risk of further injury. Man is a being oriented towards becoming and developing; and when this is recognized, illness is never simply a “mechanical failure.” Symptoms challenge the sufferer to make illness fruitful on the plane of inner development. An ideal therapy, in the process of exerting a positive influence on the disease process, would also mediate related steps in inner development. Healing, in this sense, goes beyond finding-oriented therapy. Along with its positive effect of preventing typical diabetic complications, the regulating approach introduces the risk of arresting the disease and “freezing” development. For this reason the choice of further therapies to accompany the regulation process it is of critical importance.
In 1922 for the first time a child was treated with insulin. In 1923 Banting and MacLeod were awarded the Nobel Prize for their discovery of insulin (1). Parallel to these developments, in 1920 Rudolf Steiner began to give indications on the treatment of diabetes—indications that have remained in their germinal form, undeveloped, to this day. Alongside of soul-spiritual aspects they entailed an unusual external (medicinal) approach. Understanding and developing this will require extensive work. Perhaps one day the qualitative measures of a medical art will occupy a place alongside of the regulating measures of conventional scientific medicine. A large part of the task will certainly involve developing appropriate prevention in face of the obvious influence of the factors that contribute to manifestation. The prerequisite for this is an understanding of diabetes that recognizes higher “members” of being in the human organization and develops a therapeutic approach based on this understanding.
2. How Individuality Acts in the Organism
On the foundation of the nerve-sense system, the inner being of man gains awareness of itself and the world. The colorful world of the soul and the multiplicity of sensory impressions all become conscious. Over against this thrust towards consciousness, however, the soul has another orientation which takes hold of the organism in motor and metabolic processes. The picture of the human being on which present-day medicine is based fails to see beyond the connection of inner experiences to neuronal structures. To put it positively, it is solely aware of the relationship of consciousness to the nervous system and conceives of the rest of the organism as soul-less. The criterion of brain death is based on this kind of picture. In reality every dynamic process or movement is the continuation of an inward intention; in it the inner world of the human being engages directly and immediately in the metabolic and motor organization. Only consciousness and the form-giving quality are based on the nerve organization. It is the astral organization which makes a living organism into one that is wakeful and conscious; in the upper pole of the human organization it is chiefly a vehicle of consciousness, while in the lower pole it lives chiefly in metabolic and motor functions. Consciousness and movement manifest its polar qualities. Consciousness arises through a metamorphosis of life-forces. These act in the organism’s life processes of growth and regeneration, but they can also be transformed into forces of consciousness. Here, in the domain of waking consciousness carried by thought, the astral organization has one thrust of its activity. The other, associated primarily with the lower pole, leads to metabolic processes in the life-realm which—in the case of movement, for example—may have a warming quality akin to inflammation (see below).
I-Organization and Sugar Metabolism
Each human existence poses the question how the inner being is connected with the physical body. Rudolf Steiner addresses this question while discussing the relationship of the I-organization to sugar: “Wherever sugar is present, I-organization is present; wherever sugar arises, the I-organization appears in order to give a human orientation to sub-human (vegetative, animal) corporeality” (2).
A vast gap seems to separate these two worlds, and no connection is readily evident. Here we shall explore one of the possible ways of illuminating this issue.
First of all, it is obvious that the narrowing of our attention to the ponderable aspects of substance has only made the riddle of this connection greater. The focus on dimension, number and weight reveals a material world which occupies space—the conventionally accepted “reality”—yet at the same time further obscures our view of the spiritual. This ponderable side of substance has a complement in its imponderable qualities, which are manifested in their processual action. In this connection it is revealing to observe how the sugar metabolism—particularly the action of glucose—affects the metabolic processes of the animate organism. It is the qualities of consciousness and movement that are most closely connected to sugar metabolism. Consciousness develops on the foundation of the nerve-sense system and—as any hypoglycemic knows—manifests a dependence on glucose metabolism. Movement too, as a phenomenon of the metabolic-limb system, is realized on the foundation of sugar metabolism (see below for detailed discussion).
Thus the essential manifestations of the sentient (astral) organization in the three-fold human being are connected with the sugar metabolism. In man as distinct from the animal, however, the two domains of consciousness and movement undergo a further enhancement through the individuality. In man, consciousness rises to the possibility of self-consciousness, and movement is subject to the conscious intention and control of the I. Thus the human qualities which have their organic basis in sugar metabolism point towards the I-organization.
A metabolic pathway that has been known for over a century is that of glycolysis. In 1897, Eduard Buchner succeeded in demonstrating that a cell-free extract of yeast can undergo anaerobic fermentation of sugar resulting in alcohol (3). In glycolysis, glucose which tends towards mineral crystallization—i.e., the physical level—is raised through a metabolic process to the fluid-etheric level. Given sufficient oxygen, the glycolytic breakdown of glucose does not proceed all the way to the lactate stage, but only to pyruvate, which can be oxidized to carbon dioxide in a fundamental reaction sequence. This opens the metabolic pathway of glucose to the air organism as an instrument of the astral organization. The essential connection of this metabolic pathway of glucose to the I-organization, however, resides in its serving heat and energy metabolism. The human I-organization lives in the warmth that so abundantly results from this. Substance dissolves into process, developing in its imponderable qualities towards the human spirit and becoming permeated with its life, soul and spirit. As Rudolf Steiner formulated it 1922, “the human being must have the power to dissolve sugar; his life consists in this” (4). Impairment of this power points towards the disease of diabetes. The instrument of the I-organization becomes inaccessible to its action, thus mineralizing and crystallizing in the deposited glucose whose toxicity is now so well understood.
Blood Sugar Regulation on the Background of the Threefold Human Organism
Blood sugar regulation is regarded as a function of the interplay of various endocrine hormones. It must be recognized that this view is limited to the metabolic processes in the organism which can be described in biochemical terms and offers no link to the soul and spirit aspects of the human being. Accordingly, any therapeutic approach that confines itself to the plane of blood sugar regulation always risks ignoring the inner being of man. Even a cursory look at the regulation of glucose levels, which are generally constant within narrow limits and also nearly age-stable (5), gives evidence of the soul and spirit being at work in the threefold organism. Elevations of the glucose concentration may be associated with endocrine changes in any of the following: the pancreatic glucagon (belonging to the metabolic system), the cortisol of the adrenals (more closely connected with the soul process of waking-up), the thyroid hormones (serving the unfolding of soul-spiritual life), the catecholamines (intimately linked with the development of consciousness), or stress-conditioned secretion of STH. The result is an elevation in blood sugar in connection with a soul-spiritual being oriented towards waking, i.e. to the upper pole of the human being. On the other hand, a depression of blood sugar levels is registered with every muscular movement and particularly with athletic activity. Thus when the soul-spiritual entity realizes its intentions in limb movement, it leads to a depression in blood sugar concentration as glucose is drawn into the warmth-linked metabolic processes of will activity. In summary, when the inner human being is oriented towards the nerve-sense system, a rise is observed in the glucose concentration in the blood, whereas when it is active in the metabolic-limbs system, a decrease is noted. In the first case—orientation towards the upper pole—blood glucose is “deposited” (in a relative sense). As it falls away from the higher members, the crystallizing tendency of the glucose results in a subtle sal quality permeating the organism. This can even become pathogenic in the sense of glucose toxicity. Taking HbA1c as a parameter for this depositing quality linked with the upper pole, it is of interest that HbA1c (study on 4,662 men) is associated with a death risk whether or not it exists in the context of diabetes, apparently without any threshold value. According to the study, a 1% rise in this parameter was associated with a 29% increase in risk of death for all causes, independent of other known risk factors (6). In the second case the glucose is taken up into the warmth and will-activity of the higher members. Glucose’s sal quality and its sulfuric action_substance is transformed into process_are now mediated by a rhythmic quality. As early as the 20’s of the last century, an oscillation of the fasting blood sugar was described (7). Later, a temporal correlation between rhythmically spaced insulin secretion and plasma glucose was mentioned (8).
In this way the spectrum of glucose metabolism, ranging from crystalline glucose to its dissolution in the warmth processes of the human organism, finds its place within the threefold human organism. Thus our characterization of diabetes is further differentiated as we chart its relationship to the generation of consciousness and will activity by man’s soul-spiritual being.
3. Polarity in the Clinical Picture of Diabetes mellitus
Physiological Foundations
The clinical pictures of type 1 and type 2 diabetes display a striking polarity, especially when juvenile diabetes is juxtaposed to the type 2 diabetes of the adipose adult (formerly 2b). Although in principle both forms of diabetes can occur at other periods of life as well, the primary incidence of insulin-deficiency diabetes is from childhood through early adulthood, while type 2 tends to fall in the second half of life. Besides this age difference in the occurrence of the disease, there is another clinical aspect.
A young man of about 17 has been recently diagnosed with type 1 diabetes. He is presently preparing for his abitur exams. For some weeks he has appeared pale and unwell. He complains of insatiable thirst, fatigue and weakness, and has lost approximately 15 kg. The patient is dark-haired and of gracile body type. Following diagnosis, his primary care physician has sent him to the hospital for primary care and insulin regulation (ICT).
The other type of diabetes presents an almost complete contrast: A 55-year-old female teacher, quite overweight, has for decades been in treatment for diabetes by her primary care physician, most recently due to loss of efficacy of sulfonurea medication and the need to begin insulin therapy. In complete contrast to the first patient, she feels energetic and healthy has trouble accepting the concerns of the physicians regarding regulation of diabetes and hypertension. She has a strong constitution and appears healthy, with red cheeks. While she is essentially a sociable and good-natured person, a streak of emotional impulsivity and instability are unmistakable.
These two typical patients present a polarity which can also be found in various other illnesses. Corresponding polar images are known in asthma, for example, where one sees the slender, asthenic patient alongside of the adipose one. This contrast also appears in “pale” and “red” hypertension. It is the disease polarity that reflects a dominance of the upper or lower pole of the human organization and can be described as the neurasthenic or hysterical disease type (in clear distinction from psychiatric terminology). Lab results on both types of patients reveal pathologically elevated glucose levels, and in some instances equally pathological HbA1c. Contemplating the further phenomenology, one views the full span that makes up this polarity. In the area of the life organization, there is the frailty and cachexia of the type 1 patient over against the vital appearance of the adipose type 2. In the feeling life one frequently encounters the contrast between a wakeful psyche that may be exhausted and overtaxed by consciousness, versus an emotionally oriented and sometimes impulsive dynamic. In the first case, the individuality is threatened by a lack of strength for its development, in the second by an emotional dynamic frequently experienced as overwhelming.
The patho-phenomenology outlined above provides a basis for venturing a comprehensive picture of diabetes.
On the physical plane, our attention is drawn on the one hand to the pancreas organization and on the other to the peripheral phenomena of insulin resistance, which have now been clearly determined, partly in connection with the musculature. The new classification of diabetes adopted by the American Diabetes Association (ADA) and by the WHO in 1997 (9), which supplants the preceding one, recognizes this polarity in that it contrasts ß-cell destruction (type 1) with insulin resistance (type 2) accompanied by insulin deficiency (usually relative, less often absolute).
4. Type 1 and Type 2 Diabetes mellitus
In its various forms, the disease picture of diabetes mellitus points with particular clarity to the three-fold human organism. Thus, the primary phenomenology for which the disease was named is situated in the metabolic realm. On another plane, the rhythmic system is affected in a variety of ways, ultimately extending to atherosclerotic alterations of the vascular system, which is particularly informed by rhythmic processuality. Finally, there are the unmistakable alterations in the nervous system and sensory organization.
The predominant age of manifestation is a clear initial indicator, falling as it does either in youth or in adulthood. The other forms of the illness will not be discussed in this connection. Childhood is the age of predominance of the nerve-sense organization; hence at this age we encounter type 1 diabetes, whose clinical picture clearly reveals the predominance of the upper pole. In temporal succession to the infantile dominance of the nerve-sense system comes the development of the metabolic-limb system. As we shall elaborate below, at this point the essential phenomena of type 2 diabetes manifests themselves as a disease picture in which the metabolic-limb system takes center stage. A cause for concern is the apparently increasing frequency of this “senile” form of diabetes in young patients, some under 20 years old.
newborn 2 years - 6 years - 12 years - 21 years
Fig. 1a: Metamorphosis of the human body shape, with the transition from nerve-sense dominance to increasing limb-development. The maximum manifestation of diabetes type 1—between age 14 and 20—coincides with most intense limb development. (From: Husemann A. Der musikalische Bau des Menschen. Entwurf einer plastisch-musikalischen Menschenkunde. Verlag Freies Geistesleben, 2nd Edition 1989)
4.1 The Development of the Threefold Human Organism and Type 1 Diabetes
The development of the threefold organism provides significant support towards understanding type 1 diabetes.
In childhood the entire organism has the gesture of a sense-organ. It has not yet developed an independent metabolic organization possessing its own space: “First of all, one needs to recognize that in human childhood, specifically in the earliest childhood of the human being, the entire constellation of the three systems is different than in later stages of life. In childhood we have a human organization in which the nerve-sense organs penetrate much more intensively into the two other systems than in later life in the human being. In a sense the child is really all sense-organ” (10).
Being a sense-organ also means that the child’s being still lives completely in its surroundings, in the periphery, and only gradually masters the inner world of its body. Much as embryonic development proceeds from the periphery of the developing embryo, which is only gradually taken hold of in the various processes of invagination, a similar gesture prevails on the functional plane in childhood, moving from the periphery towards increasingly autonomous existence. “When the child is quite young, all development proceeds from the head. When the change of teeth is over..., then all development comes from the chest. ... And only when the human being has become sexually mature does development proceed from the whole human being, from the limbs” (11: Rudolf Steiner’s lecture for the workers at the Goetheanum). Of course this infantile preponderance of the head organization does not imply a dominance of the forces of consciousness. At this stage these forces still must remain asleep, to awaken only much later. What we are speaking of are the formative life forces, which in the infantile organism unfold primarily in the head and sensory organization, removed from consciousness, and take hold of the rest of the body only in the further course of development. It is the path from a sensory system open to the periphery, to the development of an interior bodily space. The emanation of development from the head organization is vividly manifested in the changes of bodily form from childhood to adulthood (fig.1a). The increasing formation of the limb organization is easily recognized, and a corresponding gesture can be read in the formative metamorphosis of the skull: Initially, development of the neurocranium dominates, with a small facial skull and a narrow limb area of the maxilla and (primarily) the mandibles. Then there is more intense development of this limb-related organization (fig.1b), which recedes again in later life, particularly in the phase of old age. This formative metamorphosis quite visibly reflects the path of incarnation and excarnation of the spiritual individuality, becoming the outward gesture of an inner, spiritual process.
Fig. 1b: Formal metamorphoses of the head organization. The initial form is determined by the neurocranium. The limb organization develops as an “addition” to this and recedes again in advanced age, regaining a form corresponding to that of the infantile head. (From: Waldeyer A. Anatomie des Menschen, Part 2, 11th edition, de Gruyter, 1974)
The peak incidence of type 1 diabetes between the ages of 14 and 20 (12)_preceded by a clinically undetected phase of disease prior to manifestation_falls in the period of human development during which these critical transformations are taking place in the threefold human organism. If the metabolic-limb organism is not completely taken hold of in this process, it remains in a comparatively “infantile” configuration, creating the disposition to type 1diabetes. A significant signal in this connection is the increased frequency (by approx. 5%) of celiac sprue among type 1 diabetics, which also points to deficient action in the metabolic organization. Autoimmune thyroid disease, which is more frequent in the context of type 1 diabetes, points in the...[download for complete article]
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Girke, M. (2002). Diabetes mellitus from the Perspective of Anthroposophical Medicine (P. Luborsky, Trans.). Der Merkurstab, 55(Sonderheft-2), 4–29. [Date of translation not identified]