(Original title: "Ein Fall von chronischem Muedigkeitssyndrom" in Merkurstab 1995; 48: 34-8. English by Christian von Arnim, FIL.)

In the 1950's conditions began to appear singly or sometimes in epidemics which were characterized by pronounced fatigue with a persistent reduction in performance as well as by a series of physical and psychological symptoms which together resulted in longer-term incapacity to work.

In 1955, for example, 292 members of staff at the Royal Free Hospital in London mysteriously fell ill within the period of a few months.(1) Pain in the upper abdomen as well as pain and tension in the arms and legs suggested a depressive state or "general psychosomatic syndrome."(2) There was also evidence to suggest an infection, and extensive neurophysiologic, biochemical, bacteriological and immunologic investigations were done. With this epidemic, as with others (e.g. Lake Tahoe or Durban), possible causes under discussion were acute or chronic infections involving Epstein-Barr virus, enteroviruses - particularly Coxsackie B - and human Herpes VI virus. Rises in liter had generally been minor, and some authors spoke of "non- specific polyclonal B-cell stimulation" and introduced the concept of "immuno-dysregulation."(3)

Immunologic research has led other, more recent studies to observe deficiencies in the function of the natural killer cells as well as higher-than- average links with allergic diathesis. This is considered to be a minor cellular and/or humoral immuno-deficiency.

Despite comprehensive studies in 1992 - 163 articles on the subject appeared in major journals - no further light could be shed on this disease which has been on the increase particularly in the US and Great Britain. The term "chronic fatigue syndrome" was chosen as a basis for the work; in 1988 it was defined by the American health authorities' Centers for Disease Control (CDC) in the following way:(4)

Chronic fatigue syndrome - the exact definition demands a minimum duration of 6 months - has been called many things in the scientific literature. Some authors connect it with what the psychiatric literature at the turn of the century called neurasthenia; others see it as belonging to the symptoms linked with depressive diseases. If the emphasis is on muscular pain, which may even lead to paralysis, it is also described as myalgic encephalomyelitis (ME), while still others see a connection with viral infections and describe it as postviral fatigue syndrome.

A Case Study
Early in 1994, a 25-year-old female patient was referred to our clinic. At the point of referral she had been ill for approximately 3 months. In October 1993 the patient felt as if she had a cold for a few days, followed by the sudden onset of a high temperature of 40 degrees C and rigors which abated after three days. Since then there had been subfebrile temperatures of about 38 degrees C. The accompanying headaches and aching limbs had also persisted since that time. Pain was of a burning nature ("like sunburn"), particularly on the arms, legs and back. Furthermore, the patient described abdominal pains ("like being tightly laced up"); these pains increased in the afternoon. A great need to be warm was linked with these pain symptoms, including a desire for hot baths which provided a temporary feeling of well-being. Lack of concentration meant that the patient was hardly able to read. Her energy decreased rapidly. Having previously led an active professional life, she could only spend approximately 2 or 3 hours a day out of bed. At the onset of the disease sleep disorders appeared and loss of appetite as well as difficulty in walking because of dizziness. She also suffered from cold hands and feet from onset of the disease.

Her previous history included a fall at the age of 18 months followed by hemiplegia persisting for several hours. Besides the usual childhood diseases, which took a normal course, it is worth noting frequent 'flu infections which were all treated with antibiotics; also recurring sinusitis. At age 17 pyelonephritis required hospital treatment. At 21 and 23 she again suffered 'flu infections with temperatures of up to 40 degrees C.

Sleep had been restless from childhood, with sleepwalking and violent dreams at night. On waking in the morning, she would often have strong palpitations. Her remarkably healthy teeth were a noticeable feature during the physical examination. A very small spot of caries occurred for the first time at age 24. However, overbite (prognathism) had been corrected between the ages of eight and 14.

Other noticeable features were a high forehead and a quiet voice. Enlarged lymph nodes were not palpable although the patient reported these as occurring at the onset. On palpation, the muscles in the shoulder girdle as well as in the upper arm, the thigh and the left middle and lower abdomen were tender on pressure. Also noticeable was a slightly raised exanthem with small spots on the back of the left foot which developed at onset of the disease and which initially increased during hospital treatment but later improved. Comprehensive serological investigations had already been undertaken as an out-patient. The positive presence of Capsid-IgG and nucleotide-antigen indicated a previous Epstein-Barr virus infection. A titer of antibodies against Coxsackie B (group 2 to 5) also showed a rise on one occasion.

With us, protein electrophoresis showed a decrease in alpha I and alpha II fractions and a persistent reduction of immunoglobulin A. The white cell differential count was within normal limits, the ESR 14 mm/hr (Westergren). Initially elevated serum bilirubin (1.9 mg/dl) drew attention to a liver and gallbladder disorder. Otherwise, within normal limits.

Treatment was modeled on the second case study of Rudolf Steiner and Ita Wegman's description of characteristic diseases,(5) referring to a 48-year-old male patient who developed "depression, fatigue, apathy" at the age of 33 "following mental overexertion". Rudolf Steiner and Ita Wegman describe the disease as being caused by an astral body which - inflexible in itself - did not have sufficient affinity with the ether and physical body: "A sense of the ether body not being properly connected with the astral body results in depression, lack of proper connection with the physical body in fatigue and apathy." They recommend strengthening astral body activity with "arsenic in the form of a natural water". "Furthermore, a course of phosphorus in low dosage." In addition, they recommend rosemary baths, eurythmy therapy and elderflower tea.

We took up the suggestion made in the above case "that in the first instance the activity of the astral body should be strengthened" by treatment with mistletoe extract. We did so particularly because Rudolf Steiner writes elsewhere: "So that when we bring the mistletoe substance into the human organism we really do bring the tree's etheric substance into the human being. And the tree's etheric substance, thus transferred to the human being by way of the mistletoe, has a fortifying effect on the human astral body."(6) We chose Iscador P for the treatment and prescribed it in a physiological saline twice a week as an infusion, rising from 5 mg to 30 mg, then reducing it again to 10 mg. The infusions regularly went hand in hand with an improvement of the patient's condition. After her discharge from hospital, she described the effects in a letter in the following way: "The mistletoe infusions always gave me a boost. For the best part of a day I felt stronger, had less pain and was psychologically more stable. I also had a good night's sleep."

Oral medication consisted in Levico water as a natural source of arsenic at the beginning and later Arsenic 20x. In respect to the "course of phosphorus," we took up further suggestions made by Rudolf Steiner(7) and began with Acidum phosphoricum 4x, followed later by Phosphorus 6x in the morning and Phosphorus 30x in the evening.

In order to encourage elimination, particularly in the region of the gallbladder which is connected with will activity, we prescribed Chelidonium/ Curcuma capsules, In curative eurythmy the "R" had a beneficial effect on the respiratory and circulatory rhythms, including the problems with going to sleep and waking up. In addition, work was done with the "U" while seated. The patient was also given music therapy, using a Bordun lyre and singing to influence the tendency to slow down, stagnation and lack of mobility.

We also gave oil dispersion baths with rosemary and Citrus medica 10% ointment rubs on the legs.

The patient stayed in hospital with us for eleven weeks. In the 6th week there was a renewed rise in temperature with temperature up to 39.7 degrees C for three days. That meant a relapse, mainly with increased headaches and sleep disorders. Phosphorus 30x proved particularly helpful in relation to the headaches. The sleep disorders and other pains responded very well to the mistletoe infusions.

Except for the relapse, there was a rapid improvement in the patient's power of concentration once treatment started. She was able to read sufficiently again. Physical resilience began to improve, and walks of up to one hour became possible again. Apart from the midday rest, the patient was out of bed in the daytime. Her appetite was normal, and the dizziness improved noticeably. The patient felt her pain as "no longer so deep-seated and no longer so persistent". As a key sign of improvement she said on leaving hospital that she was able to cope better with the pain and exhaustion and that she had more ways of anticipating them and countering them with an activity.

We discharged the patient from clinical treatment in a clearly improved condition. Continued supervision by her GP will be necessary.

Conclusions and Outlook
The above case study describes the symptoms and treatment of chronic fatigue syndrome in a 25-year-old patient. To assist understanding of the disease, reference was made to the second case study in Fundamentals of Therapy by Rudolf Steiner and Ita Wegman, which also provided a basis for the therapeutic approach.

Using the "chronic fatigue syndrome" definition of the American health authorities it was shown that the symptoms of this disease are reminiscent of an inflammatory disease which does not, however, run its proper course but becomes chronic and fails to complete the healing process. These phenomena are also known from other chronic diseases. But in contrast to rheumatic diseases, for example blood analyses have not shown typical inflammatory changes with chronic fatigue syndrome, although there were minor abnormalities - also in the above case study - in the immunoglobulin titers. Recently, however, antibodies against serotonin, gangliosides and phospholipids were found in patients with the related fibromyalgia syndrome.(8) These suggestions of changes in the immunoregulation go some way to explain other symptoms of chronic fatigue syndrome which are reminiscent of allergy symptoms. They include food intolerance and edematous swellings. Such references both to allergic as well as chronic-inflammatory and immuno-pathologic diseases place chronic fatigue syndrome within the orbit of the problem diseases of our time with links - as indicated at the beginning - to the symptoms of depression. The increased incidence of the disease reflects a problem area of our age which reminds of the verse for week 46 in Rudolf Steiner's Soul Calendar:(9)

The world intends to lull asleep the vigor vested in my soul.

In his commentaries on the Soul Calendar,(10) Karl Koenig calls this verse the "winter trial"; it is a reference to the dangers to which the soul is subject when it is overwhelmed by the world with its rapidly-multiplying sensory stimuli which endanger the human being's inner unity.

With chronic fatigue syndrome we may thus look forward not only to further progress in the field of immunology and antibody research but also to seeing the degree to which phenomena of our struggle for true humanity are revealed in this disease.

Johannes Reiner, MD
Internal Medicine/Psychosomatic Division
Filderklinik D-70794
Filderstadt Germany

References
1 Kaplan B. Bericht vom Postviral Syndrom Workshop, 1985. N.Z. Newsletter 22, September 1985.
2 Braeutigam W, Christian P. Psychosomatische Aspekte der Depression. Psychosomatische Medizin p. 332ff. Third Edition. Stuttgart 1986.
3 Ewig S. Das chronische Muedigkeitssyndrom. Deutsche Medizinische Wochenschrift 1993; 118: 1373-80.
4 Ibid.,p.l375.
5 Steiner R, Wegman I. The Fundamentals of Therapy p.lOlff. Tr. E. Frommer and J. Josephson. London: Rudolf Steiner Press 1983.
6 Steiner R. The Spiritual-Scientific Aspect of Therapy (GA 313) lecture of 15 April 1921, p.81ff. Tr. R. Mansel. Long Beach CA: Rudolf Steiner Research Foundation 1990.
7 Steiner R. The Spiritual-Scientific Aspect of Therapy (GA 313), lecture of 29 August 1924 in London. Tr. R. Mansell. Long Beach CA: Rudolf Steiner Research Foundation 1990.
8 Berg PA, Klein R. Fibromyalgie-Syndrom. Deutsche Medizinische Wochenschrift 1994; 119:429-35.
9 Steiner R./Barfield, 0. The Year Participated. London: Rudolf Steiner Press 1985.
10 Koenig K. Ueber Rudolf Steiners Seelenkalender p.51. Second edition. Stuttgart 1988.