Diseases of the Respiratory Organization: Asthma
Original title: Erkrankungen der Atmungsorganisation. Asthma bronchiale. Der Merkurstab 1997; 50: 281-289. English by A. R. Meuss, FIL, MTA. Summary, with additions, of a lecture given at the Medical Congress in Berlin on 15 May 1997.
Within the spectrum of chronic pulmonary diseases, some considerable advances have been made recently in understanding pathogenic relationships and developing treatment programs on the basis of this.(7) This has made it possible to treat some conditions using differentiated progressive strategies, some of them relating to specific stages. The danger is that one then easily loses sight of the inner constitution in mind and soul, and the approach becomes less holistic, falling victim to a reductionist image of the human being. A program using anti-inflammatory agents to treat asthma thus focuses on the inflammatory pathogenesis which has been considered in some depth recently (treatment aiming at suppression) and does not take account of the individual and soul reality of the person. Efficacy may be beyond doubt, but it is equally apparent that we need to see and treat the disease in more comprehensive terms. The different diseases of the lung clearly show relationship to the soul reality of human beings. Evident examples are the connection between bronchial hyperreactivity and the emotional coloring of inner soul responses. Circadian rhythms may be found in the different degrees of bronchial inflammatory activity and obstructive pulmonary diseases,(30) pointing to connections with waking and sleeping, in short, central qualities of consciousness in the inner life. A comparable situation is the dependence of arterial oxygen saturation on the level of consciousness (waking, non-REM sleep, REM sleep(30)). The close connection between respiration as a "vital function"(16) and its function of revealing human qualities of soul and spirit in sound and speech points to the emphatic need to use the same multidimensionality in seeking to understand the diseases of the respiratory organization.
To begin with, this brief statement of aims will clearly present more questions than potential solutions, and it is hoped readers will take what follows in this spirit. An image will be sought for the respiratory organization that also considers the quality of the inner soul world. The method used will not differ from that customary in conventional science, but the range of observation will be extended to include the above-mentioned areas.
Phylogenesis and ontogenesis of the lung
In vertebrate evolution, the respiratory organization first developed into gills functioning in the region of the intestinal organization. At the level reached by amphibians, an actual lung finally developed; as a "functional memory" of the intestinal stage in evolution, this is still filled with air by the act of swallowing.(10) If one considers the way these evolutional stages came to expression at soul level, comparing the situation with that of higher vertebrates and also birds, a lively contrast is noted between dumb fishes on one hand and singing birds on the other, with the bird's inner responses given to the outside world.
At the beginning of evolution, respiration was still largely a vital process connected with the metabolic organization. It then gradually developed to the stage where the inner soul world came to expression in the production of sounds. The dim inner soul life of the fishes and amphibians, which appears sleep-like, awoke to more differentiated expression of soul qualities.
A further quality was achieved with human speech. Intonation as the melodious element, timbre and speech rhythm give expression to soul experiences. The spoken word also has sense and meaning, and thus a connection with the spiritual nature of man. By including the qualities of soul and spirit, we thus get an evolutional curve for the respiratory organization. This begins with organs close to the metabolic sphere (gill breathing), with the emphasis on the vital, living process in respiration. There follows the production of sound by lung breathers, expressing a feeling soul. The vital process of respiration evolves into one with soul qualities. In the development of speech, finally, the life of mind and spirit can sound out and reach another human being.
This evolutionary metamorphosis of the respiratory organization is also evident in ontogenetic development. The four phases of embryonic development of the lung(12) begin with the pseudoglandular period (weeks 5-17). At this stage the lung shows glandular histology, indicating its connection with the organization of intestinal glands and metabolism. In the canalicular period (weeks 13-25) bronchi and bronchioles gain in lumen; respiratory bronchioles develop. The terminal period (week 24 to birth) includes sacculation (alveolar sacs), precursors of the alveoli. The final phase of lung development (alveolar period) continues until about the 8th year of life, with new bronchi and alveoli developing. The initial stage of lung development was dominated by the relationship to the glandular organization; a further stage is the development of sound and the underlying organization to reveal the soul.
The upper respiratory tract finally seeks another orientation in morphological and functional affinity to the sensory organization. Fig. 1 provides an excellent example of the transition from the respiratory epithelium of the upper respiratory tract to the sensory epithelium of the olfactory mucosa.
The morphological aspect goes hand in hand with differentiation at soul level. We observe the transition from the unconscious "vital process" of respiration, which continues also during phases of sleep, to the development of the feeling soul coming to expression in differentiated sound utterances, until the soul wakes to perceive the world consciously through the sensory organization.
The development of the respiratory organization thus takes place within a polarity, with the metabolic system on one side and the neurosensory system on the other. The respiratory organization itself has the characteristic of rhythmic functionality (rhythmic system).
From physiology to pathology
Exact knowledge of these three functional gestures in the human organism opens up the way to understanding the potential for pathology. Two aspects may serve as an example.
The metamorphic principle we can discern in the phenomena for the respiratory organization can be traced also to the level of its supporting and structural tissues. The structural elements in the alveoli are collagen and elastic fibers. If we now follow the respiratory tract in the direction of the head organization, we see a quality of progressive solidification, beginning with the cartilaginous structures of the bronchial tree which culminate in the skeleton, again cartilaginous, of the larynx. The upper respiratory tract finally goes in the direction of bony development. For the nervous system one has the accompanying quality of solidification and sclerosis, which we only touch on briefly here, by way of example. Once one has become aware of this, a rich phenomenology opens up that can help us see the connection between processes of conscious awareness and an accompanying functional or organic solidification and sclerosing quality. The attempt to determine the function of the bony vault of the skull led only to the idea of relatively impact-resistant "packaging" for the CNS. The relationship described here, on the other hand, points to a fundamental connection between consciousness and sclerosis.
A very different situation is found in the metabolic sphere. Anyone using an approach that accepts metamorphic relationships, can hardly miss the relationship between inflammatory processes, e.g. the "digestion" of a foreign quality upsetting the organism's integrity, and intestinal digestion. Enteric and parenteral "digestion" are seen side by side in metamorphic relationship, thus seeing inflammatory metabolism to be a quality characteristic of the metabolic system.
The resulting juxtaposition of inflammation and sclerosis gives us a first image for characteristic pulmonary diseases. With acute conditions such as the different types of pneumonia and acute bronchitis, inflammatory processes, i.e. the metabolic and locomotor system, preponderate (Fig. 3). The transition from acute to chronic bronchitis on the other hand involves an indeterminable tendency to sclerosis and solidification.(17) We see dyscrinism with viscous, solidified mucus. Morphologically, the typical local epithelium will often be subject to metaplasia, giving way to more resistant squamous epithelium. Stromal fibrosis develops, so that altogether one has a many- layered spectrum of hardening and sclerotic tendencies. Compared to acute pulmonary diseases the latter show a quality that belongs to the neurosensory system. The pathological processes coming under this heading may finally end in the different forms of pulmonary emphysema.
Inflammatory and sclerosing respiratory tract diseases
The spectrum of respiratory tract diseases may be differentiated into acute inflammatory conditions, with pneumonia the most severe, and sclerosing diseases that lead to the development of emphysema and the different forms of pulmonary fibrosis, and also to bronchogenic carcinoma. This wide spectrum lying between the polar extremes of inflammatory diseases close to the metabolic and locomotor system on one hand and sclerosing diseases with their affinity to the neurosensory system on the other can also be seen in a different way if we use an approach that focuses more on the dynamic relations of the individual disease entities.
With inflammatory changes, distinction may be made between a day and a night quality.(4) The day aspect involves a metabolic situation that comes to expression in hyperemia in the vascular phase, and the accompanying exudative and finally migratory processes. It brings the destructive side of metabolism into play.(4) The pain of the inflammation (dolor) shows that the soul sphere awakens to awareness of pain.
The night aspect, on the other hand, is the healing, constructive phase that follows the destructive metabolism of inflammation. This is enveloped in the darloness of the sleep level of consciousness. The vital processes of maintenance, growth and regeneration belong to this.
This phenomenology of inflammation reflects the threefold nature of the human organism. Initially one has a greatly increased metabolic quality, with a movement phenomenology added to it in the exudative and cellular migration aspects. That is the quality of the metabolic and movement system one sees with inflammation.
This bronchial inflammation also has a rhythmic configuration in its metabolic processes. Every clinician knows the circadian rhythms in large areas of the spectrum for inflammatory diseases of the respiratory tract. The rhythmic time configuration of inflammatory changes comes to expression in this. A third quality relates to the differentiated configuration and structuring of inflammatory metabolism. It presents in connection with the neurosensory system (proinflammatory nervous system, mast cell innervation with allergic inflammation, some phenomena of bronchial hyperreactivity, finally the metamorphic connection between immunological modulation of inflammatory metabolism and neurosensory system).(4)
We thus have a third entity in addition to the sphere of the metabolic and movement system and the rhythmical time configuration of inflammation - the neurosensory system getting active in the inflammatory process (Fig. 4).
The inner gesture of an inflammatory process is that of overcoming a foreign quality. What foreign quality can we describe for inflammatory changes in the respiratory tract? As a first step we may consider an important observation relating to the susceptibility to respiratory tract infection. Different viruses were applied to the nasal mucosa in two groups of healthy subjects. The rate of infection was highest in the group that had been subject to particular stress factors.(3) This is a first, important element. The rhythmic system, of which the respiratory organization with the upper respiratory tract is part in a special way, shows an inner relationship to the soul quality of feeling, just as thoughts arising in waking consciousness relate in a comparable way to the nervous system.
When excessive demands are made, conscious awareness increases; a foreign constellation arises in this organizational sphere. The inflammatory disease developing in response to this will accordingly lead to a limitation of sensory capacity, a reduced sense of smell, with hearing, too, often reduced, and visual function impaired in the case of virus infections, for instance. The upper human being is perceived to be the bearer of a waking consciousness which is now shrouded in dullness and benumbed.
Another important phenomenon is the chilling in the human periphery that comes every time the inner life of the soul awakens (e.g. cold, damp hands if under tension). This serves as an illustration of how a part of the human organism that drops out of the warmth organism grows foreign. Frozen hands, which one can hardly move in the cold season of the year, may serve as an example. The quality of awakening consciousness is thus joined by that of developing coldness, with the human organism growing foreign. This element of getting chilled is reflected in the popular term for the condition, "a cold." A foreign quality develops in the human organism and the necessary response is a warming inflammatory disease. This also explains why cold air that cannot be given the necessary warmth and humidity in the upper respiratory tract or is not adequately warmed by this organization due to being extremely cold, may cause particular problems specifically in the rhythmic system. The connection between cold and quality of conscious awareness may also be observed in the anginal symptoms people with coronary disease develop on exposure to cold air.
When exposure to external cold or the inner elements of coldness that come on awakening to consciousness create a foreign quality, inflammation is the necessary response.
Acute and chronic bronchitis
In the light of the above-mentioned qualities of inflammation, we can first of all differentiate between different forms of acute bronchitis. After purely catarrhal acute bronchitis we have the acute exudative fibrinous form with marked fibrinous exudation. This may turn into mucopurulent bronchitis at the leukocyte migration stage. If the inflammatory process overcomes the foreign quality, recovery from the bronchitis may ensue. If it does not, chronic bronchitis develops. Again it is possible to distinguish a number of forms that differ in quality. The first one to consider is chronic catarrhal bronchitis. This form, which is still superficial, may qualitatively continue on into intramural chronic bronchitis. The most severe form of the disease is chronic destructive bronchitis with transition to emphysema.(17)
If secretion and an increase in goblet cells and peribronchial glands dominate the picture of chronic catarrhal bronchitis, metamorphic changes lead to intramural and finally destructive chronic bronchitis, with glandular elements largely destroyed and the muscular movement organization of the bronchi also affected. On the other hand there is progressive sclerosis with an increase in collagenous structures. Metaplasia may develop in the epithelial region. The cylindrical epithelium may change into more resistant squamous epithelium which also tends more towards hardening and sclerosis. Dysplasia is also common, a first sign of the second kind of sclerosing diseases - malignant changes. It is thus possible to have a dynamic picture of respiratory tract diseases, starting with acute inflammatory conditions, with transition to chronic inflammatory changes giving the connection with sclerosis, a process also seen with many other kinds of chronic inflammatory conditions.(4) The dynamic approach shows diseases involving inflammatory, predominantly metabolic changes relating to sclerotic changes and the hardening, form-changing quality that comes when the neurosensory system penetrates into the middle human being.
Allergic catarrhal inflammation (asthma) and bronchitis
With the inflammation of the respiratory tract we have been considering so far, the essential functional determiner has been the overcoming of a foreign quality. The catarrhal inflammatory changes of asthma, which are allergic in origin, have a different signature. The keynote is a direct anatomical and functional relationship to the sensory organization. A sensory process, e.g. the sense of smell in the case of pollen allergy, goes hand in hand with an inflammatory metabolic process, so that the quality of sensory perception changes.
Another striking example is pressure-induced urticaria, with an inflammatory allergic reaction in the touch-sensitive skin affecting the sensory sphere of the sense of touch. One sees the process of sensitization as inflammation-related metabolic processes awakening the senses. In contrast to bronchitis this is a metabolic process displaced into the sensory sphere. Treatment must consist in setting limits, imposing form and taking the metabolic process back to its physiological site. In the case of bronchitis treatment is given its direction by the gesture of the inflammatory process that arises to overcome a foreign quality.
Another important aspect is the disease-biographic distribution of asthma and chronic bronchitis (COLD). The threefold nature of the human organism shows a functional preponderance of the neurosensory system in childhood. Compared to later ages, it is possible for a special sensory sensitivity to develop and present as allergic diathesis, taking the form of pollen allergy, for example, or also of asthma.(23)
If the sensory orientation is abandoned in the course of development and the actual organizational sphere of the system of metabolism and movement is reached, recovery from childhood asthma is reported to be possible in more than 50% of cases. Respiratory tract sensitivity shows a corresponding change with age. Young children have been found to have greater sensitivity than older children and adults.(13) This syndrome contrasts above all with the different forms of chronic obstructive lung disease (COLD) in the second half of life. Its phenomenology of sclerosis and a hardening gesture also at the functional level in the emphysematous thorax brings the quality of an unphysiological "lung becoming head" process to realization.(20)
Following the characterization of pulmonary diseases based on the threefold human organism, we can now consider asthma.
Initially, the pathogenic principle was thought to be bronchospasm due to smooth muscle contraction. For a long time, treatment therefore consisted predominantly in bronchodilatation using beta sympathomimetics and theophylline, which is considered to act in this sense. It had been noted for a long time, however, that this did not deal with all the symptoms, leaving the bronchi obstructed. Distinction is made, therefore, between an early response and a late response with distinctly delayed onset. This quality in the time form of the disease also reflects the spiritual reality of threefoldness.
With the early response, which reaches its peak about 15 minutes after provocation,(18) constriction of the bronchial musculature has a solidifying, hardening quality. This indicates a direct connection with the function of the nervous system. The patient may also experience dyspnea and anxiety at this stage, which have conscious mind quality.
Experimentally-determined changes in airways resistance from the soul life also suggest a connection with phenomena relating to the conscious mind. Hand and feet tend to be cool during an asthma attack, a sign that the warmth organism is centralized. Asked about asthma arising from "spasm", Rudolf Steiner replied: 'With that kind of asthma, the process of senses and nerves has slipped down into the breathing process.(21)
While the early response shows neurosensory system type activity in the hardening tendency of bronchoconstriction accompanied by specific qualities of consciousness, the late response (c. 4-12 hours after provocation) in this dual process involves the opposite type of process, which is inflammation.
With this catarrhal, eosinophilic inflammation the mucosa is hyperemic and shows edematous swelling. Mediator release leads to hyper- and dyscrinia, with large quantities of viscous secretions. The surface epithelium reacts with an increase in goblet cell production (goblet cell metaplasia). Where an early response means that a quality of the neurosensory that is physiological in the upper human being has penetrated to the middle human being, resulting in a tendency to sclerosis and hardening which initially is still functional, a late response correspondingly involves a metabolic quality entering into the middle human being, resulting in often quite considerable inflammatory infiltration of the mucosa.
To a variable degree, the inflammatory process is re-configured by the neurosensory system. The secretion is not fluid but tough, viscous, tending to solidify. The mucinous matter, which varies in viscosity, will sometimes combine in Curshmann's spirals. Bronchial mucus also contains crystals, points where sclerotic processes reach their culmination. The metabolic inflammatory process enters into an area which - in terms of what has been said above - has long since developed beyond the metabolic organization. It is a metabolic process developing in close contact with the neurosensory system.
Clinical observation has shown forms of asthma where constitutionally either the neurosensory system or the system of metabolism and limbs is dominant. Here, one sees a lean, asthenic, predominantly intellectual type of person with quick reactions or a more or less round, pasty type who seems less formed out.(27)
Aspects of treatment
Conventionally, those polar tendencies are treated with bronchodilators, with antiinflammatories used according to stage. A different approach does not aim to suppress but is designed to take neurosensory and metabolic and limb system processes which are active in an unphysiological area back to their physiological situation. The clinical methods for this are still completely at the beginning and need further development and validation. However, it is always worthwhile to base oneself on a view where illness is seen as a field for inner development and no longer the malfunction of a mechanical system that needs to be corrected.
Treatment goals(6) can now be developed, basing oneself on the above view of asthma. The reconfiguring and hardening quality of unphysiological neurosensory activity in the middle human being may be dealt with by taking over the pathological process. One aspect of essential copper nature(28) evident in the drug picture is that its medicinal actions relate to the hardening and spastic processes found in all areas of the threefold organism. We may, thus, speak of an active principle taking over the pathological process to release the higher aspects of the human being from this process so that they may assume a healing function.
With regard to the reconfiguring quality in the middle human being, another medicinal agent gains significance - Nicotiana tabacum. The well- developed leaf organization of the tobacco plant shows its relationship to the rhythmic system. Focusing on nicotine as the best known constituent does not allow the true medicinal potential to emerge. Apart from alkaloid production this also consists in the power to produce nicotine to counter this.(25)
Powerful astral influences on a plant organization may induce chemical processes of alkaloid synthesis. The tobacco plant counters this with a powerfully etheric quality that is apparent in its phenomenology.(25) This can be medicinal, counteracting the astral body when it acts too powerfully on the breathing organization. The etheric organization may at the same time be strengthened by giving Prunus spinosa.
The metabolic inflammatory process which has entered into the middle human being may be countered by an active principle that limits and gives form. Suitable medicinal agents from the plant world are Citrus and Cydonia (Gencydo)).(14,31)
Thus, we get the picture of an important sequence of medicaments originally given by Rudolf Steiner: Prunus spinosa - Nicotiana tabacum - Gencydo (often prescribed as Primus spin. 5x (throat region), Nicotiana tabacum lOx (3rd/4th lumbar vertebrae) and Gencydo 1% (throat) in a one-week.
Another principle with form-giving properties are the tannins, e.g. from oak bark. Mineral principles to give form are Quartz (e.g. in Tartarus stibiatus comp.) and the relevant action of Stibium (also in Tartarus stibiatus comp, or as Stibium arsenicosum). Stibium takes the form-giving qualities of the astral body into the processes of the ether body.
A further treatment goal is to relocate a process that is pathological by being active in the wrong place. Bitters and medical plants that produce them are indicated for this, above all Veronica officinalis. Tannins and bitters may be distributed over the day (Querciis cortex in the mornings, Veronica offic. at night). A concentrated tea infusion has proved effective in either case. The use of tannins and bitter principle is another core suggestion for asthma treatment made by Rudolf Steiner. "It is always good to exhibit an appropriate dose of tannic acid obtained from sage leaves, walnut leaves, oak or willow bark, in short if one introduces tannic acid into the human organism in something equivalent to the first decimal potency, I would say, but as mere percentage. This is particularly important for the astral body in such a case. It is stimulated to extend its activities to the if one introduces tannic acid in this form. For its part, the ether body does not react to this; and one would cause disorder by giving only tannic acid.”
It is also necessary to do something for the ether body. And this is done by making an extract of the leaves of Veronica officinalis, common Speedwell, for example, to obtain above all the bitter principles such plants contain - it is also possible to obtain them from other plants, i.e. any from which these bitter principles may be extracted - and by alternating these, giving one in the morning and the other at night, if you like, you can regulate the rhythm between the astral and etheric bodies and thus initiate a healing process."(22)
This approach to treatment would go hand in hand with inhalation treatment and external applications. Gencydo may be inhaled as a form- giving principle. Inhalation of Levico Water ("arsenic inhalation") was recommended in a special case discussed with Rudolf Steiner. This, he said, could improve the problem with exhalation, arsenic making "astral activity in the bronchi" more active and "thus getting rid of exhalatory inhibitions."(29)
As to external applications, mustard packs to the lower legs bring the inflammatory metabolic process back into the lower human being. Applied to the chest they may contribute to the relief given in this respect. The spastic disease process penetrating the middle from the upper human being can be countered by bringing warmth to this area.
Eurythmy therapy has much to contribute in the treatment of asthma. The L A 0 U M sequence is developed step by step, with the vowels framed by the L, which supports inhalation, and the M, which supports exhalation.(8) Depending on the clinical picture, it may also be necessary to include the "allergy sequence."
Art therapy will base itself on the polar processes discussed for the disease. If re-configuring processes dominate - e.g. in the first "diagnostic" painting to be freely produced by the patient - dynamic forms are the aim. Conversely, if early paintings lack contour, with forms merging into one another, form principles would be brought in, also using layer techniques or drawing. In sculpture and modeling therapy, one would seek to create the Platonic bodies, for instance.
Tasks for the inner life
Asthma relates in many ways to human soul nature. Every medical practitioner is, of course, aware of these connections, but it is generally difficult to assess and describe them accurately. So many attempts to define an "asthmatic personality" have failed. Considerable help can come with the polarity we have shown, with either the neurosensory or the metabolic and limb system predominating. To illustrate this, the following characterization of a dynamically developed inner life is presented. It is based on frequent personal experience, with no claim made for general validity.
One often sees an inner life with powerful emotional dynamics relating to minor contents of the conscious mind that can be objectively described:
A patient with marked polyvalent allergic diathesis reported a conversation she, a taxi driver, had with a passenger. The passenger spoke of the death of his dog whom he would now have to "put in a hole in the ground". She could not help weeping as she spoke of her horror at someone simply "putting away" such a faithful friend and protector. Surely he deserved a very different burial!
The story, reported in an objective, sober and quite uninvolved manner, led on to floods of powerful emotion. In much the same way as the dynamic quality of inflammation penetrates the middle or upper human being with allergic conditions, it seems that here an unconquerable dynamic force penetrated into an initially calm conscious mind.
Leaving the example aside, it is possible to see that every illness poses a different kind of inner development challenge. Once this has been recognized, the individual can take it up in inner activity and let it help shape the recovery process. The exercises Rudolf Steiner gave can be a great help in the conversation between physician and patient (six qualities(19)), as can the difficult task of "meditating the breathing process in the spirit."(22) Together with the other steps taken in treatment they can make the destiny-given illness yield inner fruit. Two great men suffering from pulmonary disease, Novalis and Morgenstem, have both written about the way chronic illness can serve individualization and help one find one's I, and about the gratitude the human soul experiences in connection with this.
Matthias Girke, MD Havelhoehe Community Hospital Kladower Damm 221 D-14089 Berlin, Germany
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