Prescribing is an integral part of the practice of medicine. The prescription, whether it is written or dispensed on the spot, is fundamental to the practice of anyone who takes a pride in his or her ability to heal. Given that the doctor, alone of all people, is strictly bound to observe the Hippocratic rule of primum non nocere - even in its revised and updated form, 'the essential non-harm of all therapeutic endeavours' - he or she should, in fact, whether GP or specialist, refrain in the vast majority of cases from writin a prescription at all.
If doctors reminded themselves that the potential toxicity of any remedy is quickly made real by the absence of any pathology to justify it s prescription they would be less free with their pens. For doctors are continually confronted with problems to which they have no real answer - problems regarding diagnosis, etiology, or therapeutics. There exists a wide range of possible symptoms - which may or may not add up to a recognized pathology - and most patients present their doctor with one or more of the following problems, in different combinations :
- Diagnostic difficulties, where there are symptoms and signs, clinical or otherwise, which do not fit into any known nosologic category.
- Difficulties relating to causation, where the affection is more or less identifiable, but where no supplementary examination can throw further light on it.
- Therapeutic difficulties, where there is no genuinely appropriate remedy - either because the remedy is too powerful for the symptomatology or pathology in question, or because the right remedy cannot be obtained for any of a number or reasons, including cost.
Even if the affection is no more than the expression of a transient disturbance that will clear up by itself - or if the therapist is ignorant of the real causes, while being familiar with the physiopathological mechanisms involved - the temptation is great, and the reasons many, to give in to the demand for a prescription that is implied by the consultation. To acquiese like this in the patient's wishes, without any real justification, carries the risk of provoking undesirable reactions whose consequences are unpredictable and, on occasion, catastrophic - not least the progressive tendency to attribte to psychogenic causes things which are in fact expressions of functional disorders, and which may be spasmophilic in nature, or kinded in some other way to the motility of the terrain.
Our knowledge not only of pathological processes, but also of the physiological mechanisms behind the dysfunctions that give rise to disease, allows us to appreciate what can happen if inappropriate treatment is given. This knowledge, which is granted us by improvements in clinical science together with the insights afforded by the endocrine theory of the terrain, enables us, by analysis of the physiologica dynamics, to explain or even to foresee the failures or the inadequacies of certain kinds of treatment.
In this context, let us look at the failure of a treatment to stimulate growth. Knowing that growth hormone injections give poor results in prepubescent children, and that - notwithstanding the growth spurt at the beginning of puberty - pubery proper imposes a limit on one's final height, the specialists in question came up with the idea of delaying puberty by using an analogue of LH-RH (GnRH).
Far from helping the situation, this treatment brought about a decrease in the density of the bone matrix. It should have been obvious, however, that, since the two hypophysial hormones FSH and TSH play an important role in the everyday regeneration of bone, any treatment aimed at drastically reducing their activity would deprive GH of its means of expressing itself. For how could one imagine that any builer, no matter how skilled, could build anything at all without having the necessary materials ?
This is precisely what happens with the administration of GnRH, which, in blocking the gonadotropins, also blocks TSH and therfore prevents the necessary proteins from being mobilized, and hence from being taken up by the osteoblasts. one of the major drawbacks of blocking the gonadotropins is, without a doubt, the fact that it provokes an increase in ACTH activity, followed by a rise in glucocorticoid secretion and furher breakdown of the bone matrix.
This demonstrates how a failure to appreciate the dynamics triggered by the "knock-on" effects of a remedy - particularly a remedy with biological action - can have dire consequences. This preliminary a contrario sketch of the action of FSH, and of its relationship with other elements of the hormonal system involved in the metabolic activity that was set in motion, suggests how one might foresee the consequences of a therapeutic act, and how these complex interactions can set the scene for an illness.
The considerable progress that has been achieved in the biological sciences makes it increasingly possible to discover genuine anomalies - adding, little by little, to the information gained from clinical observation. This information only really makes sense when analysed in terms of the endocrine theory of the terrain.
For example, there exists a sophisticated protocol which allows us to determine, in vitro, the biological activity of FSH. This protocol gives a fairly accurate idea of the in vivo activity of FSH, which in no way reflects the level of FSH in the blood as measured by the standard method. This divergence is often very important.
It shows quite clearly the fundamental difference between the level of a metabolite (of whatever kind) in the blood and its real activity in functional terms. It represents a regulatory mechanism that adjusts this activity according to need. It also gives us an inkling of what is meant by relativity, a concept whose importance should not ve under-estimated.
This divergence between circulating hormone levels and their biological effect on body tissues, which was hinted at in the terrain theory formulated over 15 years ago, has been proved, at our instigation, in a doctoral thesis on the subject of gynaecology (1). By systematically comparing blood hormone levels, using the methods standard at the time, and the degree of oestrogenic impregnation of the endometrium as assessed by endometrial smear, we were able to demonstrte, in addition to the graduated nature of hormonal activity, the all - important role of congestion, in this case pelvic congestion.
It is interesting to recall here the fact that it was exactly this kind of experiment, based on biological activity, that was used to demonstrate most of the gonadotropic properties of medicinal plants. O tempora, O mores !
On a more accessible level, in order to help clinicians make a differential diagnosis between the general impression of oestrogenic activity, the exact level of oestrogen as etectable by blood tests, and the degree of oestrogenic activity in real terms, we devised a test of metabolic activity. This is based on the cyhclical restructuring of bone tissue. One part of this tes allows us, without administering the hormone, to determine in functional terms the residual cellular activty of the total oestrogen present.
This test was perfected during the course of our research - carried out in Professor Jacques Reynier's Clinic of General Surgery and Oncology at the Hôpital Boucicaut in Paris - on the prevention and treatment of osteoporosis in women who were suffering from breast cancer and for whom hormonal treatments using oestrogen were contraindicated.
According to the definition given, the concept of 'terrain' allows one to grasp the reality - that is, the ongoing dynamics - of organic functioning, its role and its importance, in terms of its own qualities as well as of the consequences that arise from it. The concept provides a means of scientifically evaluating the factors maintaining the physiological equilibrium of body functions and of their self-regulatory mechanisms.
It allows one to appreciate that the terrain is responsible for all the symptoms displayed by the organism, at any given instant. It shows that the terrain bears sole reponsibility for the expression of individual dysfunctions, and that the effect of any illness on such expression is to intensify it.
The endocrine theory of the terrain represents an attempt to explain the mechanisms that govern, regulate, maintain, and correct the functioning of the organism, second by second and at every level, with regard to its actions and reactions and the way the are expressed. It appoints one with responsibility for all the factors that play a role in the development of the morphotype, in the typology of the individual, in reactivity - in a word in the proper functioning of the organism.
It names an administrator - literally one that assumes the government, the administration of the domains entrusted to it, which it does on its own politic. This administrator guarantees for life the reactions of the organism, its ability to repair itself, and the coordination and interactions of its different parts, in the face of the many demands that are made on it, in its relations with itself as much as with the outside world.
It must be prepared simultaneously to receive information and to issue instructions ; it must be both autonomous and integrated into a self-regulatin, automatic system, and linked to each of the elements that make up that system; it must be present evertywhere; it must intervene ane interact - at every level and moment by moment - with both it self and with each of the huge information and control systems that it is linked to : the entire nervous system, and the immune system.
The endocrine system alone is possessed of all the qualities required for these functions to be caried out effectively. It assumes this role very early on : we can now show that it is active even at the foetal stage, and we can trace this activity through the four developmental stages that determine an individual's identity - foetal, neonatal, prepubertal, and pubertal. The ontogenesis and chronology of these physiological events are gentically determined. The expression of one's genetic developmental potential and of one's sexual identity is realized through, and controlled by, hormonal secretions. LH-RH (luteinizing hormone releasing hormone) appeaus from the very beginning of life, and can be detected in the foetal brain, especially in the hypothalamus, by the 6th week - that is, long before the hypothalamus is linked to the pituitary (18th week).
However, the latter is capable of reponding to LH-RH by the 10th week, and the response differs according to sex. Communication between the two organs seems to occur either by diffusion or through the cerebrospinal fluid. FSH, together with LH, is already present by the 3re month, but in a form designated 'intact', since it i smade up of subunits a and b. On the other hand, subunit a, which is the common precursor of four larger hormones (FSH, LH, HCG, TSH), is detectable from the 6th week on.
FSH enjoys a relative independence at this stage, but is present at higher levels in girls than in boys, and the FSH/LH ratio is also higher in girls than in boys; in the former the ratio increases with age, while in the latter it remains constant. One can therefore trace very clearly the role that hormones play in the functiona expression of one's genetically determined potential.
One fact that is essential to the understanding of what is to follow is that by the 6th week of foetal life the foetal ovary seems entirely capable or responding to stimulation by FSH, although in quantitative terms this chemical activity, which can be measured in vitro in the foetal ovary, only occurs in the foetus in the liver and the brain, as if at random !
Another fact essential to our understanding is the absence, or the dearth of, signs of oestrogenization in young girls, as well as those of androgenization in young boys, in spite of the respective levels of oestrogen and testosterone that are found even in infants. This helps us to appreciate the dual role of the target, in terms of its designation and its distribution. For though the main role of the pituitary gonadotropins and their hypothalamic accomplice is no longer in question, the secretory response - the character of the sexual steroids - influences, at the level of the CNS and hypothalamus, the final mode of regulation of all the endocrine functions, and determines the anatomo-physiological basis for the development of sexual behaviour.
From the foetal stage it is but a single step to puberty, and we now move on to consider the activity of FSH after puberty.
The role of FSH, like that of all the hormones, should be looked at in terms of the three aspects suggested by the endocrine theory of the terrain :
- An aspect inherent to the endocrine system's dominant metabolic function.
- An aspect inherent to the 'managerial' function of the endocrine system.
1) The organic aspect of FSH is directly linked to its gonadotropic activity :
- at the gonadal level, through its secretagogue activity ;
- at the hypophysial level, in the rhythmic pattern of the gonadal cycles ;
- at the peripheral level, with its specialized receptors.
2) The systemic aspect of FSH is directly linked to its function as an 'organizer' at the heart of the endocrine system, in both :
- its 'horizontal' hypothalamo-hypophysial funcion, i.e. its coordination of the cyclical release of the varous pituitary hormones, achieved through it priming of the other polypeptide hormone groups ;
- its 'vertical' hypothalamo-hypophysial function :
- at the gonadal level, where it regulates the level of activity - adaptive or reactive - of the peripheral glands :
- at the levelof the secretory endocrine organs, particularly those that bear directly on the efficient genital function of FSH ;
- at the level of the genital receptors.
This comprises two sub-aspects :
Again, this comprises two sub-aspects :
- At the organic level, in the allocation of the material needed for restoration or adaptation.
- At the behaviour level :
- As initiator of the mechanisms of restoration or adaptation, just after one cycle of the general adaptation syndrome has been completed.
- As a participant in muscular activity, both specific and general.
The above analysis of the multiple activities of FSH suggest that if any 'disorder' disrupts its functioning, at any level or for whatever reasons - be they linked to its potential capacities or to its basal functional expressin - the resultant 'language', in the form of apparently unconnected symptoms or of an illness, cannot but be a result of the response of the control systems to this 'disorder'.
Thus, bearing in mind this evidence of the reality of functional phenomena, we are obliged to conclude that the true etiology of illness is bound up with the organism's progressive evolution as it battles to maintain a state of coherent functional equilibrium. The main source of these difficulties is the handicap presented by the interreactive dynamics of the organism's internal dysfuncions, made worse by the constant pressure from external aggressors. One can confidently state that it is the abrupt breakdown in this capacity to maintain equilibrium that marks the starting-point of an illness.
The evidence confirms that, at root, no manifestation of illness can be traced to a single specific cause, but to a multiplicity of causes, sparked off by the kind of 'disorder' mentioned above - a structural initiating factor.
In the illustration given here, the structural initiating factor is FSH. We will now try to classify the mechanisms that lead to illnesses as different as fibroma, rheumatoid arthritis, psoriasis, and Crohn's disease.
Certain conditions appear as given for all four illnesses :
The reason for the exact siting of the fibroma in the uterus depends on a number of endogenous and exogenous factors, within or outside the syhstem of ovarian regulation, which dictate the number and distribution of hormonal receptors and the state of heightened congestion of a certain number of fasciculi, which changes the time needed for their impregnation - and hence their sensitivity and the intensity of their response to the hormones infleuncing growth. This clearly illustrates the role of pelvic congestion, of the functional activity of prolactin, and of the reactions that that activity provokes on the part of GH and insulin.
In so far as there is a close similarity between rheumatoid arthritis (RA) and psoriatic arthritis, for the sake of brevity and clarity we will look first at the common ground shared by the two diseases.
In terms of the terrain, the prime mover in both illnesses appears to be a fundamental disturbance of protein metabolism, which finds expression in an initial relative deficit in the cellular utilization of proteins. We have just seen that the natural response oestrogenic activity by the normal channels - that is, an increase in central stimulation associated with the normal functioning of FSH. The inevitable consequence of the enhjanced protein anabolism induced by this activity is a preparatory hyper catabolism, which provides the requisite building materials. The gland that participates in this activity is the thyroid, which in both these illnesses functions at a normal basal rate.
Two co-factors must also be present if either of these two illnesses is to find expression :
- The first is an overall level of equilibrium that has been maintained in its entirety : in terms of the terrain, this is described as the global 'arthritic' level.
- The second involves the idea of a pathological process of realignment akin to a tuberculin reaction (the notion of the primary lesion, BCG vaccination, or a a cross-reaction with similar consequences). This reaction has two main repercussions : it distorts the automatic functioning of the immune sytem and - even more important - because of the electrolyte disturbances associated with it, it leads to problems with protein metabolism.
These electrolyte problems, coupled with an imbalance in the overall ratio and distribution of Ca/Mg, enhance the reactivity of parathyroid hormone (PTH), which is already disturbed by the excessive thyroid stimulation that these patients are subject to. The main consequence of this is an exaggerated need for ionic carriers, and therefore a further stimulus to protein mobilization.
This metabolic dysfunction involves, through the normal functioning of the organism and its attempt to restore functional integrity, the participation of the pairing GH/insulin. This is the point at which a differentiation occurs that can lead us towards psoriasis, psoriatic arthritis, or rheumatoid arthritis.
In a case of uncomplicated psoriasis the patient's terrain is at a generally higher level of equilibrium, since the arthritic potential of the disease remains unexpressed. In RA, the patient's terrain has undergone a furher stage of deterioration - that is, the RA patient, in contrast to the psoriasis sufferer, has left behind the 'allergic' stage of the disease.
Concerning Psoriasis, the over-reactivity of GH/insulin finds expression at the cutaneous level, as demonstrted by the nature of the lesion - born of an increase in epidermal proliferation - and its vulnerbility to staphylococcal infections. The progression to psoriatic arthritis or to RA takes place as the result of an intercurrent illness - normally a haemolytic strptococcal infection - chich itself is the logical product of the kind of terrain we have been discussing.
However, other pathological factors can play a role in teh genesis of RA, during the period that the organism is undergoing endogenous or exogenous stresses - the GH/FSH ratio, for example : the dominance of GH will favour infestation by Candida or other fungi, that of FSH will favour chlamydi&e, and an even balance between the two will favour mycoplasmas.
We can therefore see, comparing one illness with another, or one patient with another patient with the same illness, the importance of relativity. Thus, the initial level of PTH will also determine whether and how the disease is expressed in the joints - either directly, as in RA, or as a secondary feature, as in the arthritic complications of psoriasis (though these latter may constitute the main external expression of the illness).
We will finish with a brief consideration of Crohn's disease. The essential difference between this disease and the two illnesses discussed above is that an overall level of equilibrium of the type called 'spasmophilic' has been maintaine; this is combined, howevr, with an initial thyroid response that is inadequate, leading to an increase TSH response to the demand created by FSH, as well as an initial shift (by way of a compensatory metabolic reaction) towards lipids and away from glucides, and the permanent correction of this by an exaggerated physiological drainage of the liver. The latter has obvious effects on the microflora of the ileum, and gives rise to the disastrous consequences that are all too familiar to students of this disease.
A final word about the therapeutic modes apppropriate to this view of physiology and to its longterm implications. The multiplicity, ubiquity, and polymorphous nature of the agents that disrupt normal physiological processes is perfectly matched by the plurality and polymorphism of the pharmacological activities of medicinal plants. This explains why we chose, very early on, whole plant extracts - or extracts that are as near as possible to this ideal - in our attempt to grapple with the complex task of maintaining or restoring homoeostasis.
1. Van Theemsche, Dr. Les traitements locaux en gynécologie. Compte-rendu du 5ème Congrès International de Phytothérapie. SFPA - Paris, 1980.
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