British Homaeopathic Journal April 1988. Vol. 77. pp. 67-71

Reidentifying the bowel nosodes

M A L C O L M ALEXANDER, F I M L S

Introduction It is now many years since Paterson's classical work on the preparation of non-lactose ferment- ing nosodes of the bowel.l Much of the nomen- clature used by him as well as many of the techniques have now changed beyond all recog- nition. However, bacteriological nomenclature, although now standardized internationally, 2 is still subject to fairly regular changes and dis- putes reflecting the many different approaches to the analysis and definition of species.

Even when the International Committee on Systematic Bacteriology reports its findings through a Judicial Commission, or when one of its specialist sub-committees gives a view on the status of a species, the findings of the specialists who sit on these committees may still remain the subject of much dispute, and consequently the cause of considerable confusion in the labora- tory. The naming of a species is, at best, the result of an agreement between the majority of international experts in the field.

Nowadays strains which are subjected to detailed analysis are routinely preserved by freeze drying and often deposited in national culture collections. It is therefore possible to compare and contrast strains which are described by different authors and determine their degree of relatedness.

Biochemical and genetic data are used to indi- cate the similarity between strains. These tech- niques include DNA hybridization which gives an estimate of the compatibility of D N A from two or more strains, polyacrylamide gel electro- phoresis which gives bacterial protein profiles which can be compared by densitometryfl and plasmid analysis 4.5 which allows the comparison of strains after plasma extraction and separation by electrophoresis.

Biochemical techniques continue to play a major role in bacterial identification although the tests have been refined and 'packaged' in many cases to allow the simultaneous examin- ation of 50 or more tests in a single kit. Many newer enzyme techniques have been added to the original sugar reactions described by Dr

Bach 6 at the International League Congress of 1927.

Computer-assisted identification of 'difficult' organisms may be based on the results of several hundred tests instead of the four sugars orig- inally described. Sugar tests with peptone water are still used to a certain extent but the original batch of four would be consisdered insufficient to distinguish pathogenic from non-pathogenic strains of bacteria such as the common bowel organism E. coli. This organism is known to have many thousands of biotypes some of which are non-lactose fermenting and some of which may be enteropathogenic.

Another feature of modern bacteriological analysis is the recognition that species and bio- types merge into one another rather than form- ing distinct entities. The relationship between E. coli and Shigella is a good example, where the historical species definition, based heavily on the pathogenicity of Shigellae, has masked the close biochemical and antigenic relationship between some strains of the two genera and the genetic relatedness of the two genera as a whole.

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Sycosis Among the species which have been particularly difficult to identify using the original description are those associated with the 'miasm' known as 'sycosis' described by Hahnemann in its.associ- ation with chronic disease. The name derives from the fig-like lesions on the skin which are associated with this group of diseases. Orig- inally, 'sycosis' was associated with gonorrhoea but in time it was realized that gonorrhoea was not always the precursor of sycosis although in its 'suppressed form' the association may have been valid.

Among the prominent symptoms of sycosis are a urethral discharge, especially in woman, fig warts on the skin, and catarrh from any of the mucous membranes. In a group of twenty-two cases identified as falling into the category of sycosis, each case yielded a diplococcal organ- ism 7 on stool culture.

68 British Homceopathic Journal

Figure 1. Two photographs of Sycoccus taken from Paterson's 1933 paper 'Sycosis and Sycotic Co.'

Figure 2. Two recent micrographs of Acinetobacter calcoaceticus Lwoffii, showing both the diplococcal and bacillary forms described by Paterson. (Photographs by Malcolm Alexander)

Volume 77, Number 2, April 1988 69

Bacterial flora of sycotic disease In the case of the disease which dermatologists would identify as sycosis barbae, i.e. a skin con- dition resulting from the infection of hair fol- licles and formation of an abscess, the most common organism isolated is Staphylococcus aureus. However, it has been reported that diplococcal organisms have also been isolated from sycotic lesions of the face, e.g. 'Diplococ- cus albicans'. 8 It is, however, unclear whether this organism is a member of the Micrococ- caceae family and thus a coagulase negative sta- phylococcus or if, as a result of inadequate technique or the poor description of some spe- cies, it is in fact a gonococcus. The pus cells from these lesions contain an intracellular diplococcus with a 'coffee bean' appearance. Unless great care is taken to prevent overstaining these diplococci may be missed. Some authors have placed special emphasis on these organisms when found in eye infections, and they have been described as Trachomacoccus 9 by one author. They apparently are frequently found on the conjunctiva. In the early part of this century they were known as the gram positive Pseudogonococcus , a name which arose because of their similarity to gonococci when stained by aniline dyes.

Pseudogonococcus and Acinetobacter Thus the exact identification of the Pseudogonococc i is elusive; they might be part of the genera Staphylococcus or Micrococcus. Similarly they could belong to any one of a number of generae which include gram negative diplococci, e.g. Neisseria and Acinetobacter. Naturally it is difficult to ascribe a name to organisms isolated in the early part of the cen- tury unless freeze dried strains are available for comparison. This is rarely possible.

The description by Paterson in 1933 of a gram negative diplococcus which decolorizes with difficulty and tends to become gram positive in secondary or old cultures, grows at room tem- perature and on plain agar, grows in the bacillary form in broth and as a diplococcus on solid media, suggests an organism of the Acinetobac- ter group. This group contains a number of organisms which fit the above description and which have been known by many epithets, including Diplococcus mucosus and M i m a poly - morpha (the classical 'false neisseria gonor- rhoea').

The most recent description of this organism comes from a very elegant study of Acine tobac-

ter by Bouvet and Grimont 1~ who describe it thus:

The cells were gram negative but sometimes difficult to destain, i.e. sometimes gram positive. Cells from over- night agar cultures were predominantly diplococcal. Cells from broth culture were predominantly short rods and occurred in pairs, and occasionally short chains (3-6 cells) or long rods (5-6 microns).

This description fits the earlier one of the Syco- coccus by Paterson extremely well. The entero- coccal organism which has been described as the sycotic nosode is now firmly established as a gram positive streptococcus, generally identified as Streptococcus faecalis or faecium.

One organism in the Acinetobacter group known as Acinetobacter calcoaceticus Lwof f i i is gram negative; it produces no reactions in pep- tone water sugars; it usually grows on Mac- Conkey agar without either oxidizing or fermenting lactose.

TABLE 1 Strains and species showing the same biochemical reactions with four sugars as the seven species described by Paterson

B. morgan

B. Gaertner

B. no. 7

B. proteus

B. mutabile

B. dysenteriae

B. faecal~

Morganella morganii, Proteus mirabilis (4% are sucrose +ve) salmonella sub gen. IV, Aeromonas salmonicida, Edwardsiella tarda, Escherichia blattae and Hafnia alvei (7% are lactose +ve) Salmonella paratyphi A, S. subgenus I and II, S. cholerasuis (27% are dulcitol +ve) Citrobacter koseri (dulcitol 45% +ve, lactose 85%, sucrose 45%. Enterobacter cloacae (dulcitol 12% +ve, lactose 76%). Edwardsiella hoshinae, E. tarda biogroup 1, Obesumbacterium proteus biogroup 2, Proteus myxofacients, Pr. penneri, Pr. vulgaris biogroup 2. Morganella morganii (lactose 3% +ve) Salmonella subgenus III (lactose 33% +ve) Salmonella subgenus IV (lactose -re) Shigella dysenteriae, Sh. flexneri, Sh. boydii, Salmonella gallinarum, Salmonella typhisus.

This could be Bacillus faecalis alcaligenes. If so it would now be Alcaligenes faecalis but might be misidentified as Acinetobacter c. Lwoffii or possibly Neisseria denitrificans but gram film would probably differentiate. It is most likely to be an enterococcus.

70 British Homteopathic Journal

Clinical aspects of Acinetobacter infection T h e Acine tobac ter is a f r equen t colonizer of human skin, of low pathogenic i ty but capable of infecting im m une -compromised pat ients . It is recognized as a pa thogen in cases of pneumonia and meningit is and is a serious cause of infection in pat ients with burns.

Some pat ients with eczema and psoriasis become heavily but t ransiently colonized by Acinetobacterc . Lwo f f i i and this organism is also f requent ly found on wet par ts of the body, especially toe webs, axillae and genitalia. How- ever, it does not fo rm a significant par t of the normal bowel flora.

Identification and isolation of gram negative bacteria Samples f rom stools are inoculated onto a vari- ety of laboratory enter ic media to isolate gram negative non- lactose fe rment ing bacteria. These include MacConkey agar no. 3, desoxycholate citrate agar (D C A) , Salmonella-Shigella agar (SSA) and selenite broth . Fol lowing inocula- t ion, the faecal material is s t reaked out for 'dis-

crete colonies ' and incubated at 37~ for 18 hours.

Selenite broth is an enr ichment med ium for some non-lactose ferment ing bacteria and is sub- cultured at 18 hours on the solid agars descr ibed above. All agars are examined for non-lactose ferment ing colonies and these colonies are sub- cultured onto a s tandard laboratory medium, e.g. MacConkey no. 3, for purity and identification.

The tradit ional me t h o d using pep tone water sugars with A n d r a d e ' s indicator may be used, but this has now been generally superseded by an identification kit with computer-ass is ted analysis, e.g. the A P I 20 E system.

An assessment of the relationship between Paterson's identification scheme based on peptone water sugar reactions and modern classification Four pep tone water sugars are quite inadequate for bacterial identification because so many new species and biotypes of each species are now recognized. General ly identifications are based

TABLE 2 Biochemical reaction of organisms from normal and abnormal bowel flora to Paterson's four sugars. After Holmes et al. 198611

Glucose Lactose Sucrose Dulcitol

Citrobacter sp 3 species + 85-99% 9-60% 1-45% E. coli + 70% 35% 64% E. tarda bg 1 + - - - - -- E. tarda bg 2 + - - + -- Hafnia alvei + 7% - - -- Morganella morganii (Pr. morganii) + 3% - - - - Proteus mirabilis + - - 4% - - Proteus vulgaris bg 1 (penneri) + - - + - - Proteus vulgaris bg 2 + 6% + - - Proteus vulgaris bg 3 + - - + - - Providencia rettgeri + (acid) 3% 38% - -

(Pr. rettegi) 13% (gas) Providencia alcalifaciens (Pr. inconstans) + (acid) - - 80% - -

67% (gas) Salmonella I + - - - - 97% Salmonella II + - - - - + Salmonella III + 33% - - - - Salmonella IV + - - - - - - Serratia sp + (acid) 2-99% 1-99% - -

1-55% (gas) Serratia liquefaciens and marcescens + (acid) 2-14% + - -

34-35% (gas) Shigella sp + (acid) 1-11% 1-11% 1-18%

Notes: Last two species of Serratia are the most common species causing human disease. Assume glucose is acid and gas positive unless otherwise stated. +ve = 90%; -ve = 1% or 0%. bg = biogroup.

Volume 77, Number 2, April 1988

on compar i son of the b iochemica l reac t ions of test organisms wi th those of ' con t ro l ' organisms. The react ions of the cont ro l o rganisms would normal ly be expressed as pe rcen t age posit ivi ty for each b iochemica l r eac t ion and the tes t organ- isms could also be c o m p a r e d with one a n o t h e r and with the species type s t ra in using D N A homology exper imen t s . These da ta are pro- duced by publ ic hea l th l abora to r ies , e.g. t he Pas- teur Ins t i tu te in F r a n c e and the Cen t r a l Public Hea l th L a b o r a t o r y Service in Eng land . T he results of these analyses are f requen t ly pub- lished in jou rna l s such as the I n t e r n a t i o n a l J o u r n a l o f S y s t e m i c B a c t e r i o l o g y so tha t the con- clusions may achieve s ta tus in the 'scientific com- muni ty ' . However , t he resul ts of such tests may remain inconclus ive and it is con ' tmon to assign a 'probabi l i s t ic ' ident i ty to o rgan i sms w h e n this s i tuat ion arises.

T h e organisms descr ibed by Pa t e r son are shown in Table 1 t oge the r with a var ie ty of o the r organisms which could p roduce ident ical bio- chemical react ion. It is c lear f rom these results tha t careful a t t en t i on needs to be paid to ident i - f ication and n o m e n c l a t u r e if work on nosodes is to deve lop b e y o n d the i r use in single cases and part icular ly if an a s sessment of the i r effective- ness is to be made .

Table 2 lists a var ie ty of o rgan i sms which fo rm par t of n o r m a l and a b n o r m a l bowel flora and shows the i r b iochemica l reac t ions us ing Pater- son ' s or iginal four sugars. A large n u m b e r of pa thogen ic and n o n - p a t h o g e n i c organisms could easily be confused wi th one a n o t h e r but , in addi-

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t ion, it is clear tha t there is a var iety of bio- chemical profiles which could fit some of the species l isted because of the range of var ia t ion within each species.

References 1 Paterson J. Lecture demonstration showing the Technique

in the Preparation of the Non-Lactose Fermenting Nosodes of the Bowel and the Clinical Indications for their Use. International Hornceopathic Congress Transactions, Glasgow 1936.

2 Approved Lilst of Bacterial Names. Int J Syst Bact 1983; 30: 1-420.

3 Alexander M, lsmail F, Jackman PJH, Noble WC. J Med Microbiol 1984; 18: 55-64.

4 Farrar WE. Molecular Analysis of Plasmids in Epi- demiologic Investigation. J Infect Dis 1983; 148: 1-5.

5 Archor GL, Marchmer AW, Vishniausky N, Johnston JL. Plasmid-Pattern Analysis for the Differentiation of Infect- ing from Non-infecting Staphylococcus epidermidis. J Infect Dis 1984; 149: 913-20.

6 Wheeler CE, Bach E, Dishington TM. The Problem of Chronic Disease, papers read at the International Homveo- pathic Congress, 1927; London, Bale Sons & Danielsson, 36 pages. Reprinted in Julian Barnard, Collected Writings of Edward Bach. Hereford: Bach Educational Programme 1987.

7 Paterson J. Sycosis and Sycotic Co, Br Horn J 1933; 23: 160-86.

8 Herzog, Klinische Monatsblaetter fuer Augenheilkunde 1904; 42: 177.

9 Michel. A.f.A. 1886; XVI. 10 Bouvet PJM, Grimont PAD. Taxonomy of the genus

Acinetobacter. lnt J Syst Bact 1983; 36: 228-40. 11 Holmes B, Dawson CA, Pinning CA. A Revised Prob-

ability Matrix for the Identification of Gram-Negative, Aerobic, Rod-shaped, Fermentative Bacteria. J Gen Micro 1986; 132.

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