To gain insight into myocardial infarction (MI), a condition occurring with increasing frequency in our present/ highly developed civilization, an attempt will be made to derive cardiac function from the morphogenesis of the heart during the embryonic period.

The diagrams which follow immediately raise the question: Is the heart the outcome of opposing forces like the Chinese yang and yin, with yang (= ouranos, heaven) and yin (gaia, earth) forming a direct connection? At the point of intersection, tao, the universal cosmic spirit, the very essence of the cosmos, is active (Fig. 1). Compared to this, the created world and the human being with the heart as the center has differentiated from a monistic, single center that becomes polarized in the course of human and natural evolution. The polar forces act on the center and the center acts back on to them (Fig. 2). Figure 3 illustrates the forces of the liver, lung and kidney acting on the heart.

In the past it was thought (Hensen 1876) that the unpaired "tubular heart" derives from the fusion of paired elements at the early stage of cardiac development. If, however, we consider the monistic, single form of the heart and the fact that separation into a left and a right heart is not complete in the embryo, with an admixture of blood in the ventricle, the obvious conclusion would be that the form of the heart does not result from a primary polarity but from an undifferentiated, nonpolar tissue structure. This would be in accord with the role of the fully developed heart which is to perform a middle function at the center of the circulation between respiration and metabolism, so that the blood returning to the heart from the superior vena cava, which therefore belongs to the sphere of the head, senses and nervous system, and from the inferior vena cava, coming from the metabolic system and limbs, is unified through cardiac activity. We shall come back to this later.

Recent research(1) has shown that the first unpaired cardiac tube derives from the cavity of the myocardial pericardium, in conjunction with the omphalomesenteric veins which at this stage are still imperforate. The first contractions of the heart occur even before a continuous cardiac lumen has been established between omphalomesenteric veins and the pharyngeal arch arteries.(2) The onset of contractions in an as yet capillary heart at the beginning of the 4th week marks the onset of a function that has its final clinical significance at the end of life (unaided by machines)."(3) The paricardial cavity gives rise to the myoepicardium and the endocardium. (The heart spontaneously begins to beat at an early stage of embryonic (GRAPHIC, PG 8)

development (4th week).) The extracellular matrix between these two is to be regarded as "a multiphase mixture of substances, the components of which are not able to move freely as in the fluid. A network of delicate fibers gives this 'cardiac jelly' (extracellular matrix - author). The cardiac jelly retains its form, returning to its original form after external deformations."(4) ...experimental interference with glycosaminoglycans causes interference with loop development" (in the heart).

"Two processes may thus be distinguished in the development of the lumen: 1) the development of a median, unpaired lumen from a large number of isolated vesicles via an unpaired vascular plexus, and 2) the processes by means of which this plexus connects with the primarily paired omphalomesenteric veins. The following modalities may be considered: either the two veins fuse end-to-end, or their blind, distal ends become part of the unpaired myo-epicardial mantle, where they fuse side-to-side at the lower end of the cardiac tube."(5) Here it is important to point out that the extracellular matrix - in terms of the evolving heart the "cardiac jelly" - plays the leading role in organogenesis, in this case of the heart.

Quite generally, the following is said of the extracellular matrix:(6) In recent Decades, the ground substance of embryonic connective tissue, now generally called the 'extracellular matrix' (ECM), has been accorded in-

(GRAPHIC, PG 9)

creasing significance in relation to cell migration, differentiation and morphogenesis (author's emphasis). It consists mainly of collagen, in the embryo mainly type I, II and IV collagen, glycosaminoglycans such as hyaluronic acid, chondroitm-6-sulphate or keratin sulphate and specific high-molecular proteins such as fibronectin and laminin. Glycosaminoglycans are highly hydrated; together with free fluid they largely determine ECM consistency. The ECM is the micro environment for all cells that lie between the limiting basal membranes. It is also the space, or substrate, within and on which cells migrate."

It is evident from the above that the extracellular matrix acts as a base not only morphogenetically but also functionally and dynamically, and this is very much connected with the morphological and functional plan for the organism as a whole. Rudolf Steiner's reference to the "mutual perception of organs" presupposed an organization that played a perceptive, and above all also a correlating role in relation to all special, differentiated organ functions.

Morphology and function of the heart - the active middle element in the threefold organism

Priority goes to the formless content Over the empty form. Content brings form ivith it; Form is never without content.(7)

In the embryonic period the heart still has uniform, monistic character (see above), and the future left and right hearts have absolutely the same type of wall, and their electrolytes (potassium and sodium) are also the same. When pulmonary respiration begins, the heart polarizes into distinctly right- and left-sided heart functions. The right heart is then largely under the influence of the metabolism and nutrition, the left heart under that of oxygen and nitrogen-based pulmonary respiration. The influence of the liver on the right heart is highly significant: 70% of the blood from the inferior vena cava derives from the liver, the rest from the neurosensory region (superior vena cava) and the pole of limbs and movement (inferior vena cava). Due to this polarization the myocardium of the left heart develops about three times the thickness of the thin-walled right myocardium. Mean end-diastolic cardiac output for the left heart is about 85 cm3 It is interesting to note that (according to Landois-Rosemann) left ventricular end-diastolic output is 15-20% less than right. In people with no physical training the end-diastolic left-ventricular volume is 120 - 136 cm3. It is highly significant that the endsystolic ventricular volume is between 45 cm3 and 70 cm3 of residual blood. This is the blood that is not returned directly to the circulation but is, as it were, added to the next blood volume entering the ventricle and mixed with it. We might say that the residual blood in the heart is potentized into the new atrial blood.

For postnatal, permanent cardiac function it is important that in the muscular interstitium and within its well developed capillary network almost half (40%) of the blood coming directly from the heart muscle discharges through the foramina venarum minimarum into the atria. Reference to the internal circulation of the heart has been made elsewhere,(8) indicating that the heart's own blood moves from the coronary arteries via the arterioles into the myocardial matrix, with up to 40% not drained off via the system of cardiac veins but - as shown above - flowing directly into the atria via the foramina venarum minimarum. It should be noted that the matrix system of the myocardial interstitium connects with what has been said of embryonic development, i.e. always retains its connection with the matrix system, or immune system, of the organism. In this respect the internal heart tissue is an essential part of the immune system and the continuous "organogenesis" of the myocardium. Against this background, we shall now consider the prevention and treatment of MI.

Prevention and treatment of MI

If we ascribe a form-giving and "sensory" function to the myocardial interstitium and especially the ECM, the ECM may be seen to play a key role in the etiology of MI; other factors being the combining and rhythm- generating, controlling function of the venous blood on the one side and the arterial on the other. The key role in establishing the rhythm of cardiac action as a whole (both left and right) belongs to the bundle of Hiss, or atrioventricular bundle, in the cardiac septum, m terms of substance this is close to the matrix. It is embedded in the primary cardiac ground system from which both the endocardium and the pericardium also develop.

Negative stress

If we take it that the heart with its unifying and rhythm-generating function between the upper, neurosensory pole and the lower pole of limbs and metabolism is subject to excessive demands, this must have consequences for the central, intermediary and interstitial fluid processes of the myocardium discussed above. Polarization of the blood system into arterial (blood connected with inhalation and oxygen) and venous (blood with high carbon dioxide levels that has anabolic functions) is overcome by the cardiac action insofar as the heart's own blood goes partly to the right and partly to the left atrium (see above). This is the basis of the heart's unifying function in this respect.

We speak of "negative stress" when too much is demanded of this balancing function. Increased arterialization, i.e. increased arterial flow both to the left heart and through the coronary vessels, above all the left coronary artery, and delayed drainage of myocardial blood via the foramina venarum minimarum and the sinus venosus result in a pre-infarct situation, i.e. partial or extensive edema in the left myocardial interstitium. "Actual changes are found in the terminal flow system. The most severe damage to the parenchyma is always on the venular side."(9) This seems significant because it supports the view that venous drainage in the myocardial interstitium is delayed, causing venostasis. The use of Arnica would thus appear to be indicated. According to Doerr,(9) vascular thrombosis is found in only just under 50% of people who died within a short time of MI. It is probable that these thromboses developed only immediately after complete cessation of cardiac activity. Even on its own the stress-induced rise in catecholamine levels, causing increased arterial vascular tone and sympatheticotonia extending as far as the arterial vessels supplying the left heart, suggests that too much has been asked of the balancing function of the heart. In terms of the whole heart organism, excessive demands from the upper neurosensory sphere on the one hand and excessive demands on the organism from the metabolic side on the other mean a kind of "short-circuit" in the balancing function of the heart. This results in greatly increased systolic function and increased diastolic activity in the heart. The tension between left and right is taken beyond the physiologic level. It is important to remember that the process affects the myocardium directly, with arterial flow increased and venous drainage delayed. Together these two factors cause connective tissue edema in the heart.

Positive stress

Negative stress has been shown to consist in excessive demands on central cardiac activity. Failure of the rhythm-generating and unifying function reflects disordered psychic activity at the organic and physiological levels. Positive stress consists in addressing oneself in a purposive, ordered fashion to the environment. Using the resources of psychic and organic heart forces to bring plans and lifestyles to realization has a beneficial effect on cardiac activity. We might say that it strengthens the heart when we use the rhythmic and ordering function of the heart to bring our life goals and tasks to realization.

Prevention of potential MI also involves taking a good look at the professional and personal life and establishing order in them, consciously creating a new balance between personal aims and demands made by the environment.

Prevention

As the polarization of left and right cardiac action is increased in the pre- infarction state, Aurum/Stibium is most important for prevention. A brief characterization of the two substances follows.

Aurum activity, which is also reflected in the homeopathic drug picture, combines the active processes found in the metals belonging to the exterior planets - warmth quality (lead), light quality (tin) and chemical quality (iron). In gold these activities are on the physical level (gold is the heaviest of the seven main metals). The gold action on the heart takes the form of increased arterial congestion, mainly in the region of the left heart, and congestive cumulation of connective tissue fluid. This explains why Aurum is also used to treat "red" hypertension, hypervolemia and polycythemia. Potentized Aurum reduces excessive activity of the left heart.

Stibium is the genuine polar opposite of Aurum. According to Rudolf Steiner this as yet "unearthly" metal combines the interior planetary metals silver, mercury and copper in itself, but in such a way that the sulphurous heat energy immanent in antimony takes effect in the fluid processes, mainly of the venous system. The subterranean nature of antimony is evident in its diamagnetic behavior (magnetized antimony needles are at right angles to the north-south axis), liquid antimony expands on cooling, like water (and unlike the "earthly" metals). Toxic effects include reduced blood coagulation, but potentized antimony encourages the form-giving forces in fluid processes, above all in the blood. Elsewhere we were able to speak of an endothermic heat process in venous blood. The heat processes in the sphere of arterial blood are exothermic (the left heart releases measurable heat energy: ca. 35 calories per minute and 100 g of heart weight). Aurum/ Stibium medication reduces excessive activity of the left heart and the flow of arterial blood to the heart, as already mentioned. It also reduces the flow of venous blood to the right heart. Antimony thus subdues the metabolic process coming from the metabolic sphere and above all the liver, a process which is embarrassing the right heart. Aurum relieves the left heart of its tendency to become too compact and too physical.

A modification of Aurum/Stibium is Strophanthus comp., also with Aurum and Stibium. The Strophanthus component is a major substance- based process at the pre-infarction stage because Strophanthus seed, or rather its potentized glycoside, captures an excessively powerful light-adrenals process. The preparation is above all indicated in cases where one may speak of the heart being stressed by civilization factors, especially if there are signs of bradycardia. Another pre-infarction medicament to be mentioned here is Strophanthus/Nicotiana comp. This is especially indicated with coronary sclerosis. It is not primarily for the prevention of MI but for the treatment of coronary spasm. Strophanthus/Nicotiana comp. contains Strophanthus kombe e semina 5x, Nicotiana e foliis 9x, and Plumbum mellitum 14x.

Aurum/Stibium or Strophanthus comp. with Aurum/Stibium may regularly or occasionally be combined with the organ preparation Cor Gl in the 6x or 8x. This acts on the etheric heart organization, above all vitalizing the inner processes in heart muscle described in this paper and the "matrix organization" of heart, as we call it. Another organ preparation which may be indicated with arrhythmia is Fasciculus atrioventricularis Gl. Given in the 4x or 6x, this has also proved helpful in the treatment of heart block.

A third preparation for infarction prophylaxis is Aurum/Stibium/ Hyoscyamus. The Hyoscyamus (henbane) part of this is indicated when the heart rhythm is put under stress because reproductive processes are not sufficiently incorporated, which essentially means that the sentient and life organization active in the reproductive organs is making itself independent. The heart is then put under stress by elements coming from the lower human being (see Goethe, Wilhelm Master's Journeyman Years).

Treatment of MI

Two medicaments are available for immediate use:

1 Naja tripudians. Cobra venom, in the 6x, 8x - 12x, twice daily, together with

2 Arnica e planta tota 8x, 12x, 15x, at least once daily.*

Arnica therapy is so important in the treatment of MI that a brief outline of the Arnica picture is given below.

Arnica e planta tota ferm (Arnica, Arnica montana; Compositae). Like many members of the daisy family Arnica relates especially to the generation of warmth, its flowering process being highly developed. It also has an affinity to the silica process that goes beyond the family type. It grows on native rock in medium and high mountain ranges and is finely hairy, which points to the silica process. As with all alpines, there is a powerful relation to light. The herbaceous growth and the preference for wet and even swampy grasslands point to another process in the plant which is the polar opposite to the other - a relationship to the vegetative, watery sphere. Arnica develops its growth and its medicinal actions between light and chemism.

As a medicinal plant Arnica relates to the bee. Apis may be said to stop the warmth process between blood and connective tissue, so that edema develops at the capillary level. The Arnica action intervenes more in the venous blood process which isolates itself from the intermediary connective tissue metabolism and the fluid processes. Venous congestion and the heat congestion associated with this are characteristics of the Arnica action. Used medicinally. Arnica sets the circulation in motion, especially in the venous part. The sphere of action of Arnica in the organism is the relationship between primarily active connective tissue and connective tissue ground substance on the one hand, and congestion of venous capillaries which may go as far as venostasis on the other. Mentally and emotionally the Arnica picture shows a relationship to the Aurum picture. The mental state goes in the direction of melancholia with marked irritability and self-centeredness (obstinacy). The whole musculature is affected, including myocardium and myocardial interstitium. Uterus highly sensitive to fetal movement in pregnancy. The heart symptoms to be emphasized are as follows: Arnica is an important medicine for incipient and actual infarction because venous congestion and inadequate drainage of venous blood with hemorrhaging develop in the myocardial interstitium.(10)

Naja may be replaced with Lachesis muta, bushmaster venom. Both snake venoms counteract interstitial edema. With Naja, tissue liquefaction is the dominant feature; with Lachesis necrosis of myocardial tissue.

The venoms most widely used in homeopathy are Lachesis muta, Naja tripudians and Crotalus. Lachesis is one of the most powerful venoms. The chemical potency of the salivary gland secretion is increased to the level of venom production. The toxic effect consists in proteolysis and paralysis. The venom thus delays blood and lymph coagulability on the one hand, and coagulates blood on the other. Inflammation rapidly ensues, with connective tissue edema and bluish red discoloration in the area penetrated by the venom, and the vegetative defense reaction is inhibited; no wall of leukocytes forms as an inflammatory reaction; instead of pus there is dry tissue necrosis (resembling anaerobic gas gangrene). Not only salivary gland activity is increased in venomous snakes but also the whole digestion - stomach, pancreas and liver. Limb development and hence external mobility has been withdrawn and become internal. Shoulder and pelvic girdle are rudimentary, the development of vertebrae and an extended vertebral column taking their place. The connection between salivary (parotid) gland and gonads is generally known. In venomous snakes this polarity is enhanced. Emphasis on the vegetative pole in these snakes is also evident from the fact that the left lung is non-existent or only rudimentary. Regression of the right carotid artery in some species also shows that emphasis. The vegetative pole is connected with the venosity and right-sidedness (liver on the right). Oddly enough, the drug picture has left-sidedness. (See also Lachesis action on the right heart).(11)

Constitutional treatment

Constitutional treatment must also be considered. Someone with a phosphoric constitution is given Phosphorus 20x, 30x every second day, someone with a lymphatic exudative constitution Calcium carbonicum 30x or Conchae (oyster shell) 30x by injection every second day.

Occasionally there will be an "arsenic constitution" in the background. These are neurasthenic, neuropathic individuals who are thoughtfully critical, and inclined to be melancholic; body build generally leptosome, with low blood pressure, extremities apt to be cold. Background arsenic therapy may also be considered for circulatory collapse due to the infarction, with the blood pressure going down, cold sweats, and the danger of fluid accumulating in the pericardium and pleura. This already takes us to the sequels of MI.

Veratrum (Veratrum album, white hellebore, Liliaceae) may play a vital role if the blood pressure drops to an extreme degree (v. s.) and the patient develops dyspnea (Fades hippocratica). Veratrum album 6x is given three times daily, both orally and parenterally.

Veratrum points to the heart-kidney connection. Strictly speaking, the action on the kidney consists in directing a psychic organism that is putting a strain on the heart to the kidneys. Veratrum is also the first-line treatment for shock-induced circulatory collapse and for renal failure.

With Veratrum and arsenic treatment the focus is on the heart-kidney relationship. Another important medicine for incipient circulatory failure following infarction is Tartarus stibiatus (potassium antimony tartrate). It is indicated when the fluid element is putting a strain on the heart from the metabolic or liver aspect. Transudates develop in the region of heart and lung, and edema results. We use Tartarus to treat the influence of the liver on the heart (potassium salt plus antimony), as discussed for Aurum-Stibium therapy above. Tartarus stibiatus is the first-line treatment when in a case of MI the right heart is put under a strain that comes from the liver.

External applications.

Compresses on the heart using Urtica essence and/or Orthoclase essence (K/Al/Si308 = potash feldspar). The temperature of the compresses would depend on circumstances. Patients often complain of burning sensations in the cardiac region and between the shoulder blades (Phosphorus), and in that case cool compresses are used. Many feel the need for warmth, however. Arnica essence may also be used for the compresses: Dilute a scant tablespoonful of Arnica essence with 1/4 liter of lukewarm water, soak a cloth in this, wring it out and place on the heart. Cover with flannel. It is most important to pay attention to the peripheral circulation - whether the feet are cold (see Arsenicum and Veratrum) or are felt to be hot, which is uncommon.

For the differential drug diagnosis distinction must thus be made between

1 Veratrum album 4x, 6x

2 Arsenicum album lOx, 20x or 30x {v. s.)

3 Nicotiana tabacum 15x, 20x

4 Carbo Betulae 20x, 30x.

Careful distinction must be made between these. Thus Arsenicum and Nicotiana tabacum may be considered if the periphery is icy cold (esp. Nicotiana), peripheral circulation is reduced, and in either case aggravation during the night and anxiety states dominate the picture. Carbo has slight bluish discoloration of lips and skin (excess carbon dioxide, none of the anxiety symptoms seen with Nicotiana and Arsenicum).

Summary

The intention was to show that with MI, the ultimate pathological process is failure of the heart's rhythm-balancing function. The pathological process occurs in the myocardial interstitium. Reference was made to the key role played by the extracellular matrix which no longer performs its balancing function in MI. Interstitial edema develops. Impairment of capillary circulation in the surrounding areas is secondary. This approach assumes MI to be based on an allergic process. Readers are reminded of bee sting or serum-induced MI, though this is rare. Prevention and treatment of MI relates to polarization of the heart through the arterial and venous circulations on the one hand, and to the view that with a disposition to infarction, the heart's unifying tendency is weakened in the myocardial interstitium. Preventive treatment is designed to counter extreme polarization between left and right heart, whilst MI treatment aims to overcome the loss of tension between left and right heart from the periphery and gain the time needed to restore a balanced relationship between left and right cardiac activity. With MI, the tension between left and right has gone; the heart tends to regress to the embryonic condition, with the function of the left heart coming close to that of the right heart. Essentially this means left heart failure. The fact that it is almost exclusively the left myocardium which infarcts, and that this causes the loss of tension between left and right heart, supports the view that in the infarction process the heart regresses to the tension-free state of the embryonic stage.

In conclusion a mantra-like thought expressed by Goethe where he speaks of the heart's balance-creating powers of transformation: What more can human beings gain in life but that the nature of divinity show itself, as it lets firm, solid matter dissolve into spirit, and firmly preserves what spirit has achieved.(12)

Heinz-Hartmut Vogel, MD Boslerweg 17 73087 Eckwaelden Germany References 1 Hinrichsen. Hunwnemhyologie. Abschnitt 10,2: Entstehung des Herzens, S. 211,215-17. Berlin: Springer 1990.

2 Ibid. S. 216.

3 Ibid., S. 33.

4 Ibid., S. 217.

5 Ibid., S. 216.

6 Ibid., S. 19.

7 Goethe, Paralipomenon zur Faustdichtung.

8 Vogel H-H. Das Herz. Merkwstab 1991; 44:294.

9 Doerr W. Organpathologie vol. 1 pp. 127-8. Stuttgart: Thieme. 10 Vogel H-H. Wege der Heilmittelfindung (ways of finding the indicated medicine). Eckwaelden: Natur Mensch Medizin 1994.

11 Beitraege zu einer medizinischen Menschenkunde (contributions to the study of man in medicine) Band 1, Teil 1, S. 191-2. Heidelberg: Haug 1984.

12 Goethe. Im ersten Beinhaus (in the first ossuary).