The aim of this review has been realised, in that, by utilising homeopathic methodology, the genus epidemicus has been identified and subsequently six main remedies considered as being appropriate for treatment of the documented stages of the disease process from inflammation through to necrosis in susceptible individuals. The information reviewed concerns both the accepted theory and practice of treatment of the disease process in N.F. which can result in states of inflammation, suppuration, gangrene or finally necrosis as a consequence of puncture wounds (caused by drug injection), repeated over time or infected by an exogenous pathogen in those with a compromised immune system (C.I.S.), and the theory and practice in homoeopathy for treatment of similar states, with similar causes. This paper supports the assertion that homoeopathic treatment is a viable alternative when antibiotics are proving ineffective.
To identify a group of appropriate homoeopathic medicines, which can potentially be used in threatening or actual suppuration in abscesses and necrosis of same or other local sites, in susceptible individuals. In this review I consider particularly those of homeless status who are also intravenous drug users (especially of heroin).
- To discuss risk factors which predispose some individuals to a lowered immune system who are therefore more susceptible to developing or contracting Necrotising Fasciitis (N.F.)
- To examine details of documented and possible bacteria involved in the process of suppuration leading to necrosis.
- To consider relevant homoeopathic philosophy in relation to susceptibility, maintaining causes, and predisposition.
- To outline the disease process involved which may lead in some individuals, to developing N.F.
- To present a resume of individualised homoeopathic remedies potentially suitable for use in all stages of the disease process outlined in Objective Four.
In June 2000, 22 drug users in Scotland and 21 between Dublin and Manchester (1), died after contracting (or developing) Necrotising Fasciitis, and again in July 2001 eight individuals were affected, either fatally or requiring surgical debridement and/or partial amputation. These cases were thought to be the result of using contaminated heroin for injecting in cases of drug addiction. (2) The condition itself is described as “… a rapidly progressive soft-tissue infection that involves superficial and deep fascia leading to thrombosis of cutaneous vessels and gangrene of underlying tissues.” (3) It was first documented by Fournier in 1883 (4), and Meleney isolated a particular bacteria as a causative factor in 1924. (5) The term ‘necrotising fasciitis’ was ascribed to Wilson, who, in 1952, noted that an “essential component” of gangrene with a specific bacteria, involved the deep fascia. (6) The condition can occur in any anatomical location, usually at a distance from any trauma but also at affected sites. Other names that it is known by e.g. Fournier’s Gangrene (genital), Meleney’s Ulcer or Hospital Gangrene etc., often indicate either anatomical sites or places where infection was contracted or developed. (7) Conventional therapy involves antimicrobial treatment with e.g. Penicillin, aminoglycoside, metronidazole etc. and Hyperbaric Oxygen Therapy (HBO) and surgical excision, including debridement and amputation when considered necessary. (8)
There are several factors, which are conventionally regarded as leading to possible susceptibility in contracting or developing N.F. The greatest of these is that of having a ‘compromised’ immune system, which is noted in conditions such as; Diabetes Mellitus, malignancy, renal impairment and trauma. (9) In this discussion, which is intent on reviewing the specific factors in relation to the circumstances of intravenous drug users who may be homeless, two of the above noted conditions are worthy of further exploration. In the first instance, similar to Diabetes Mellitus II, where a state of ketosis may develop due to the inability of the body to utilise carbohydrates and glucose, it is worth pointing out that it is also possible for ketosis to develop in states of starvation or eating disorders. The result being, that fats and proteins become the primary energy sources, which may produce ketones in the blood, and thereby lead to ketoacidosis (10). In the report of a survey carried out in 1999 by the Office of National Statistics titled, ‘Health and Well Being of Homeless People in Glasgow’ published in June 2000,
“19% of respondents had eaten only once in the day prior to interview and 5% had not consumed any food at all. Fifteen per cent of respondents did not consume any hot food (excluding drinks) in the day prior to interview.”
It would seem probable that in such circumstances, it would be possible for heroin addicts who are also of homeless status to be at similar risk to developing a condition akin to ketoacidosis, which may also result in renal damage. In addition, it is well known that nutritional deficiencies play a decisive role in the prevalence and severity of microbial diseases in under privileged people. The rate of wound healing is also markedly influenced by dietary factors especially in deficiencies of some vitamins including Vitamins C, E, K, B6 and Minerals such as Calcium and Iron. (11)
The citing of ‘trauma’, as a further risk factor is particularly apt in the present examination of the incidence of N.F. in intravenous drug users. ‘Trauma’, here being defined as: “…any injury caused by a mechanical or physical agent.”(12)
Heroin addiction most often requires the use of intravenous means whereby the subjects repeatedly inject the drug, causing puncture wounds, often several times daily for, perhaps, a duration of some years, with little or any use of disinfecting measures. Thus creating a higher than usual risk of infection at multiple sites, most often on arms and legs but the groin area is also used amongst others, as more accessible veins become unusable.
In the outbreaks of N.F. documented here, this is all the more relevant, for it has been discovered that all the cases had a significant factor, i.e. the injection has been made directly into muscle tissue or accidentally into other tissues when a vein has been missed. (13) . This assertion also brings to bear the immune inhibiting effects of drugs themselves as a risk factor to infection which include non-steroidal inflammatory preparations such as aspirin, ibuprofen, naproxen etc. that inhibit the inflammatory mechanism that makes tissue repair possible. Steroid use is particularly implicated, possibly due to the fact that cortisone interferes with the production of antibodies under certain conditions. This immunologic inhibition cannot account entirely for the infection enhancing effect. In addition to interfering with antibody production, cortisone influences many other physiologic processes, some of which may affect directly or indirectly the response of the body to infection. Interference with the inflammatory response and with the activity of the reticulo-endothelial system, disturbance of the intermediary metabolism, and activation of proteo-lyctic enzymes (14) are but a few of the effects of cortisone that might be important in this regard.
The habitual use of heroin, (the popular name of diacetyl-morphine, a semi- synthetic compound derived from morphine and stronger than the natural drug), which has its effects principally on the Central Nervous System (CNS) and also affects some peripheral organs such as the alimentary tract and the respiratory system, is a definite factor in compromising the immune system. Morphine usually neither eliminates the psychological perception of pain nor blocks the sensation. Although there are exceptions, the person knows that pain continues, but he or she is not disturbed by it. The associated fear and tension subside so that the pain becomes bearable. These reactions signify the effects on the CNS but the opiates may also change the activity of peripheral nerves that conduct messages to and from the brain. The enkephalins involved are found in neurons in the spinal cord and portions of the hind and mid-brain which transmit pain and related sensory signals (for example, heat and cold), and in parts of the mid-brain associated with movement, mood and behaviour. The enkephalins are also found outside the central nervous system in the neurons of the periphery and the gut. (15) These effects have relevance in two areas in connection with this investigation: the fact that the addict despite feeling hunger is able to ignore these feelings. This can result in the production of acids in the gut which having no food to breakdown will tend to become destructive to the alimentary tract itself. The other danger is that by being able to ignore sensations of heat, pain and even fear for health, any inflammation, abscess formation or numbness can continue unabated.
In the past, several types of bacteria have been identified as being involved in the presentation of N.F. On this basis, two types of N.F. had been labelled, i.e. i) Polymicrobial, involving a number of organisms in various combinations and ii) Pure group A Streptococcal, which is said to be haemolytic, (rupture of RBC membrane). (16) In direct relation to the cited outbreaks, Clostridiun Novyi Type A among others, was isolated from eighteen of the people who developed N.F. in June 2000. (17) Some of these bacteria are known as being indigenous (ie. present in a healthy state) to the human body, e.g. Bacteroides, Staphylocci, Streptococci, Pseudomonas aeruginosa, Clostridium etc.
Two aspects are known to be observable concerning these micro-biota:
- That most micro-organisms commonly harboured by the body in a state of health are capable of exerting a wide range of pathological effects under special conditions and,
- Many of the micro-organisms classified as pathogens, indeed probably all of them, often persist in vivo without causing overt disease. (18)
As has been previously noted, nutritional deficiencies, exposure to toxic agents, and certain kinds of physiological stress are among the many causes of disturbances associated with disease processes caused by indigenous microbiota. In other words, some form of pathological or at least abnormal state must exist before indigenous bacteria can multiply to such an extent that it causes deleterious effects. George Bernard Shaw echoed Pasteur who suggested that a physiological disturbance might in certain cases be the primary cause of the infectious process rather than its consequence, when he said: “The characteristic microbe of a disease might be a symptom instead of a cause.” (19) Early in the investigations of 2000, Dr Laurence Gruer, Consultant to the Greater Glasgow Health Board commented that:
“It is quite possible that no single cause for the illnesses will be identified. Many injectors in the affected areas of Glasgow have said that their recent supply of heroin has required unusually large amounts of citric acid to be added before it can be dissolved for injecting. A variety of different bacteria normally found on the skin have been isolated from tissue or blood from several patients. It is likely that injection of the unusually strong heroin and acid mixture can cause severe damage to muscle and other tissue. This may then create the conditions for harmless bacteria present in heroin or carried on the needle from the skin to cause serious infection.” (20)
Clostridium Novyi, Type A, was isolated in some, though not all, recent or current cases of N.F. at the time and described as an “…’anaerobic’ bacteria-that is, they only grow in the absence of oxygen (dead tissue). Some Clostridium can not only cause severe infection in damaged tissue but can also produce very powerful toxins. They can also exist in for years in dust or soil as dormant spores, only becoming activated when the conditions are right.” (21) But it was only previously been known to cause serious infection in domestic animals; very rarely in humans and is commonly found in soil and animal faeces. Other types of Clostridium have been located in intestinal flora of the human where it is non-spore forming.(22)
It is therefore a matter of postulating whether the Clostridium isolated in the cases cited, is the actual cause originating in contaminated heroin supplies and therefore exogenous. In classical infections of exogenous origin, the determining etiological event of the disease is said to be exposure to the infective micro-organism. This was yet to be made clear in the present situation. The author has been unable to locate documentation on this particular strain of Clostridium (ie. Novyi) in standard textbooks on microbiology and this raises two questions:
- In which conditions, if any, has it been previously been isolated?
- Or, is it a possible new mutation arising from this particular combination of factors met in this incidence of drug injectors?
In indigenous microbial disease, the immediate cause is the environmental factors that upset the biological equilibrium normally existing between the host and the microbial agents.The documented factors common to many (but not all) of the affected were:
- They are all Heroin Injectors, whose supply source may or may not have been the same.
- Many, if not all, used more Citric Acid than usual to dissolve the drug for injection.
- The subjects all injected into muscle or tissue other than a vein.
If the source of supplied heroin was the same and all users of this supply increased the quantity of Citric Acid – plus the involvement of the injection into muscle and other connective tissue, (which is not particularly uncommon in heroin addicts), not all heroin injectors likely to have used this batch of the drug under these circumstances, have succumbed to either infection or development of N.F. It would have to be considered somewhat as a result of this combination of factors or it would suggest another unidentified predisposing factor. Dr. Jai Lingappa, Epidemic Investigation Officer at the Centers for Disease Control in Atlanta, commented that:
“A lot more work still needs to be done to clarify how exactly the Clostridium Novyi is contributing to the illness……..We also want to learn more about why these people became sick and others didn’t.”(23)
The purpose of reviewing this serious condition, (N.F), with the prospective use of Homoeopathic medicines for treatment in mind, is to put forward an approach that will to a degree bring into congruence the determinants of infection and the determinants of disease and present a means of treating the pathological processes which can ensue from both exogenous and indigenous causes, and to understand and control the processes responsible for converting so-called infection into overt disease. This approach is found in Homoeopathic philosophy and practiced in the homoeopathic treatment of both individuals and genus epidemicus. Relevant theory is summarised in the next section.
Even from the viewpoint of conventional medicine, a person in robust health may easily resist exposure to even the most virulent microorganisms. The degree of resistance can change from hour to hour and day to day depending upon exhaustion, starvation, cold, overwork, emotional stress, etc. It has been stated clearly in a standard textbook on microbiology used in all universities and medical schools in the U.S., that the susceptibility factor is so significant that it is virtually impossible to decide the infective dose of a specific microorganism. (24) In the cited cases of those developing N.F., this study has identified at least some of the major factors related to increased susceptibility to developing a seriously life threatening infectious disease and this is further explained in Homoeopathic philosophy by considering not just the ‘compromised’ immune system but by also considering the effects on the Defence Mechanism of the human organism. This defence mechanism is known in homeopathy as the Vital Force and is considered in terms of electro-dynamic vibrations, which involves a great degree of complexity.
“The vital force level of the human organism is considered the dynamic plane, affecting all levels of the being at once with varying degrees of harmony and strength. It is a highly complex, fluid, flexible, and energetic process, simultaneously responding to and affecting the surrounding environment……The whole organism, and any component of it, can be strengthened or weakened depending upon the degree of harmony, resonance, and force of the morbific or therapeutic influence applied to it.”(25)
When the strength of a noxious trigger is stronger than the strength of the vital force, the defence mechanism is called into play to counteract the stimulus. If the vital force is so weakened by exciting and maintaining causes, any powerful noxious trigger would alter the state of the entire organism without adequate defence, and death would rapidly ensue. There is a latent period before actual symptoms develop, during which the defence mechanism begins to adjust to the effect of the stimulus. In bacterial infections this ranges from hours to days.
From this premise it should be clear that disease is a result of a morbific stimulus which resonates with the particular susceptibility of the organism. This stimulus is known as the exciting cause and may be a microorganism, a foreign chemical, an emotional shock, a vaccination, etc.
Maintaining causes are those factors external to the organism which, because they continue to affect the individual over a period of time, maintain the individual in a weakened state eg. Lack of nutrition, unsanitary or damp living conditions, drug addiction; conventional drugs prescribed for long periods or repeated often in short periods of time (also regarded as Iatrogenic miasms), repeated emotional trauma, in short, many of the factors previously mentioned. But yet, the predisposition underlying much of these areas of susceptibility is the Fundamental Cause.
“Useful to the physician in assisting him to cure, are the particulars of the most probable exciting cause of the acute disease, as also (are) the most significant points in the whole history of the chronic disease to enable him to discover its fundamental cause, which is generally due to a chronic miasm. In these investigations, the ascertainable physical constitution of the patient, his moral and intellectual character, his occupation, mode of living and habits, his social and domestic relations, his age,… etc., are to be taken into consideration.” (Para. 5, The Organon of Medicine, Samuel Hahnemann, 5th & 6th Edition, B.Jain Pub. Reprint 1992)
The theory of Chronic Miasms is complex and involved and it is not within the scope of this review to give a full explanation of such. (Please see Bibliography section for further study). In summary, it is sufficient to say that a miasm is a resulting stereotypical disease condition, sometimes heredotransmissable, which can be latent or active, acute or chronic. Nevertheless, it is always the result of both a maintaining cause (hence the lingering disposition) and an exopathic exciting cause (the noxious trigger).
There is one miasmatic pattern, relevant to this review that has been recognised for most of Homoeopathy’s history ie., the Luetic Miasm. This particular pattern is in essence one of destruction and disintegration. There will often be a predilection in the family history to similar patterns of destructive illnesses, eg. Syphilis, alcoholism, conditions where ulceration has taken place or a tendency to necrosis, etc. When active and predominant in an individual, this pattern will taint and distort expression at all levels, mental, emotional and physical. In the individuals involved in the outbreaks of N.F. cited , the destructive pattern is essentially seen in addictive habits concerning the use of heroin and often several other substances. There exists a craving for acidic or spicy foods in general, there is a metabolic tendency to acidity and they are often of a temperament conducive to states of rage; that is when not suppressed by drugs. The effects of this pattern whereby heroin addiction is a symptom result in destruction not only of the immune system and particular bodily organs and systems e.g. the heart and circulatory system, but as noted, affects the intellectual faculties, the emotional responses and subsequent behaviour destroys family and social contact.
With regard to the ‘contagious principle’, Hahnemann, (1755-1843, founder of Homoeopathy), though not having the benefit of a microscope, put forward an uncannily accurate explanation more than half a century ahead of Robert Koch and others. He suggested in 1832 (Lesser Writings, p.758) that cholera, for instance, was caused by “…an enormous …brood of excessively minute, living creatures.”
He also regarded each epidemic (acute miasm) as having features of its own (the genus epidemicus) And since it is always the product of a single cause it will, in all individual cases, be amenable to one and the same specific remedy, the epidemic’s simillimum. (26)
THE DISEASE PROCESS
In this section, the disease process taken into account is that which begins, for our purposes, from the available information on the circumstances and states of individuals who were involved in cited presentations of actual or threatening N.F.
They are individuals who are:
- Intravenous Drug users i.e., heroin injectors;
- Experience a chaotic lifestyle, which often includes bouts of homelessness.
- Deaths predominantly in females. (27)
In the first assertion, two factors are particularly important:
1a). Lowered Immune System due to chronic heroin use (poisoning);
1b). Bodily subjected to repeated trauma from puncture wounds.
In the second assertion, two factors are again considered of import:
2a). Immune system further compromised by chaotic lifestyle, especially during times of homelessness, resulting in:
- Reduced intake of adequate food and nutrition.
- Exposure to the elements.
2b). Less access to medical services when required, unless in an emergency.
This information provides some clues to the degree of susceptibility at the general level of health and the particular susceptibility at the physical sites by repeated trauma and risk of infection.
Schematic Evolution of Possible Disease Processes in General Terms
- Comp. I. S. –> Repeated Puncture Wounds –> Abscess Formation –> Necrosis of tissue at local sites with possibility of developing N.F.
- Comp. I.S. –> Vein injection infected by exogenous pathogen –> Septicaemia –> Possible development of N.F.
- Comp. I.S. –> Injection into Fascia, infected by exogenous pathogen and/or high levels of acid at site creating environment for mutation of indigenous bacteria. –> Rapid development of N.F.
Schematic Evolution of Disease Processes through Particular Levels and Systems
This section is based on available information from previous documentation and current GGHB Bulletins.
The following section is adapted from ‘Thorsons Encyclopaedic Dictionary of Homoeopathy’ by Harald Gaier. (Pgs. 130-132, Pub. Thorsons,1991) due to its admirable scientific clarity.
DISEASE and DRUG ACTION in HOMOEOPATHIC CONGRUITY
Applied therapeutic science requires a coincident parallelism between the symptom complexes of both the disease and the drug of choice on as many of the first seven under-mentioned points of comparison as possible. Obvious incongruity in any comparative aspect frequently amounts to symptom dissimilarity in the case, allowing for the elimination of many otherwise eligible remedies, facilitating the process of repertorisation.
- 1. Generic Similarity
Homoeopathicity of type of affliction; describes the identity in the class of affections induced by both the natural disease of the patient and the experimental disease of the drug to be used: eg. I) if the illness is febrile, the remedy must be pyro-genetic; ii) if the disease is an inflammation, the drug of choice will be an irritant, etc.
- Causal Similarity
Homoeopathicity of formative affectors; means that the antecedent concomitants present when the disease arises will substantially narrow the field of contenders among drugs to be used: eg. I) neuralgia induced by injury to a nerve is different from one brought on by shingles and that again is also distinct from one that comes on with gout.
- Parallels in Symptom Modalities
Homoeopathicity of modalities. Meteorological and thermal influences, cosmic rhythms, mental factors, physical conditions (including movements and rest), relation to food and drink, location, laterality and time are circumstances that can contribute to making symptoms I) better or ii) worse, iii) appear or iv) change.
- Symptom Character Resemblance
Homoeopathicity in the quality of abnormal sensations. All sensations have a distinct character: for instance, a gnawing pain, a burning pain, a tearing pain etc. are distinctly different from each other. The character of such sensations are to be alike in both the disease and the drug action.
- Constitutional Compatibility
This describes the aggregate of patients’ common features. It is used to identify patients according to their temperament, appearance, certain characteristics of behaviour and their variance from the normal, which should be compatible with the corresponding remedy.
- Synchronicity of Symptom Evolution
Homoeopathicity of pharmocodynamic devolution; meaning that various developmental aspects of the disease process of the patient must synchronise with the developmental pathogenicity inherent in the drug to be applied.
- Concordance of Emotional Symptoms
Homoeopathicity of disposition; matching emotional and/ or the intellectual symptoms. Since mental and emotional symptoms are in evidence well ahead of functional and morphological changes when disease develops, they frequently provide very early indications for homoeopathic treatment.
- Matching of Three or More Guiding Symptoms
Multiples of semiological homoeopathicity. Reliance on the coincidence of three, but preferably more, striking symptoms, evident in both the artificial illness of a drug as well as in the phenomena of a disease, rests on the mathematical law of permutations. If three distinctive symptoms of a case can be found to have been experimentally produced by a medicine, there is already considerable likelihood of its acting on the same parts and in the same manner.
Many homoeopaths are guided by Robert Gibson Miller, who in 1910 proposed ranking the above points of comparison in the following order of priority:
- matching mental & emotional symptoms;
- correspondence between modalities of time, season, motion, locality, sensation etc.
- similarity of pronounced cravings and aversions;
- menstrual, or hormone-related, changes in state in both the natural and the artificial diseases;
- resemblance between the particulars as well as the generals of both diseases, where only the peculiar, unexpected, striking or unaccountable symptoms are of significance;
- common symptoms, as featured in standard non-homoeopathic disease classifications.
The Simillimum is the medicine, which in its manifestations most clearly reflects the total symptom picture of the individual’s diseased state, which will certainly cure that patient, if the patient’s condition is within reversible limits. (28) In relation to the symptoms available from the documentation in the author’s possession, which have little or no individuality, it is less likely that the most accurate simillimum will be found. But as will be explained, it is not always the best remedy to prescribe even if it were possible (ie, by taking information from those who are displaying symptoms associated with the recent outbreak or who are thought to be at greatest risk.)
Contra-indication Against Administering Simillimum
In a patient, whose disease is terminal and which may be in its final stages, namely where the life force is hopelessly overwhelmed by the forces of disease, or in many emergencies, it is absolutely contra-indicated to prescribe the individual’s simillimum, which would, in these circumstances, only be able to produce an aggravation hastening death. In such an instance functiotropic, organotropic or pathotropic remedies ought to be the homoeopathic drugs of choice, with the intention of inducing a measure of improvement for the limited period remaining to the patient.(29 Therefore, the remedies identified by using predominantly common, general and particular symptoms which have no modalities, will be sufficient when given at the appropriate phase in the disease process and may reflect more the nature of the Genus Epidemicus rather than the simillimum of the individual patient.
FINDING THE GENUS EPIDEMICUS
Although, it is not as yet possible to find, or would in some cases be inappropriate to utilise the simillimum, many of the above mentioned principles will still be employed to find the remedy or remedies that come closest to the picture of the genus epidemicus. This means that, depending on at which stage of the disease process the remedy is administered, there is a possibility of preventing the development of N.F. or reducing the effects of infection before it reaches a life threatening degree.Symptoms will be taken from all general and particular disease processes outlined above:
Repertorisation using Synthesis (R.H.S.) Edition 5.2 Edit. Dr. Frederick Shroyens