NationalLibraryOfScotland/medical-history-of-british-india huggingface dataset:
3
A superposed infection of nonspecific bacteria may give rise to a diph-
theritic inflammation such as occurs in specific bacillary dysentery.
Liver abscess is a frequent complication (11-33 per cent., Strong), 22 the
amœbæ being demonstrable in the contents and walls.
With regard to the details of the morphology and life-cycle of pathogenic
amoebæ, much confusion and radical difference of opinion among observers at
present exists.
A form of dysentery associated with the presence of motile amœbæ in
the stools had long been recognised, but, in 1903, the work of Schaudinn 1 9
f i r s t
gave definition to the subject and indicated lines of research which have since
been followed by several other observers.
He distinguished two types of intestinal amœbæ (i) Entamœba coli, a
harmless commensal, and (ii) Entamœba histolytica, identified by him with
that previously described and figured by Jürgens 12 as the causal organism in
three cases of dysentery orginating in China.
He did not find that these amœbæ could be cultivated outside of the body
and based his description of them on the morphology and life-cycle as studied
by him in the intestinal contents and, in the case of E. histolytica, in the
intestinal wall of men who had died of dysentery and of experimentally infected
cats.
Viereck24 in 1907, Hartmann10 in 1908 and Werner 2 7
also in 1908, follow-
ing Schaudinn's methods of observation, described another species of amœbæ in
the stools from cases of dysentery, (Entamœba tetragena) allied to E.
histolytica.
Viereck2 4
c o n s i d e r e d
t h a t
t h e n a t u r a l o c c u r r e n c e o f p a t h o g e n i c a m œ b æ
in water had not been convincingly demonstrated, and that such amœbæ had
not been proved to multiply on artificial media ; on the contrary, he empha-
sised the fact that the motile amœbæ found in stools appear to die off rapidly
after their discharge from the body.
Werner2 7
a t t e m p t e d t o s e c u r e m u l t i p l i c a t i o n o f p a r a s i t i c a m œ b æ o u t s i d e
the body by transferring to fucus agar medium fresh stools containing
vegtative forms of E. histolytica and E. tetragena : in no case did he see multipli-
cation of these amœbæ ; (the number of observations is not stated). On the
other hand, he found on the agar medium, growth and encystment of what was
apparently a different species of amœba ; this organism, which was characterised
by the presence of a contractile vacuole in the vegetative phase and by
round double-contoured cysts in the resting condition, he was inclined to
identify with Amœba limax, (Vahlkampf), a free living form.
He shewed that when cysts of this amœbæ were artificially fed to house-
flies, such cysts passed through the alimentary canal apparently unchanged so
B 2
that they germinated when the fæces of the infected fly were transferred to a
suitable medium.
He suggested that the amœbæ appearing in cultures from human fæces
might have had a similar history.
In marked opposition to the conclusions of the above observers are these of
Musgrave and Clegg, Lesage, Walker and Noc.
In 1904 Musgrave13 and in 1906 Musgrave and Clegg, 16 using an agar
medium with an alkalinity of 1 per cent., cultivated amœbæ from the stools in
cases of dysentery in Manilla, from water, soil and a variety of outside sources.
They did not discover, in any these amœbæ from different sources, charac-
ters which would serve to distinguish different species amongst them or
finally to distinguish these cultivated forms from those found microscopically
in the infected intestine and liver.
They considered it probable that any free-living amœba might, under cer-
tain conditions, become a pathogenic parasite.
In. 1905, Lesage13 stated that he was able to obtain, in 7 out of 20 cases of
tropical dysentery, cultures of amœbæ from the stools, using washed gelatine
as a medium. These amœbæ he considered as identicial with E. histolytica
( Schaudinn) .
In 1908, Walker 2 5
, u s i n g M u s g r a v e ' s m e d i u m , o b t a i n e d f r o m f æ c e s o f
different animals 44 cultures of what he considered parasitic amœbæ among
which he distinguished 10 species ; he did not succeed in obtaining a culture
from human fæces.
Noc,19 in 1909, by the use of a gelatine medium 0 . 5 per cent. alkaline in
reaction obtained cultures of amœbæ from (i) liver abscess pus, (ii) the stools in
cases of dysentery, (iii) the water supply of Saigon (French Indo-China); these
amœbæ he considered to belong to one single species, identical with that
found microscopically in the fæces and in liver abscess pus, and he looked upon
them as the causal organism of amœbic dysentery and hepatitis.
In the medical literature on amœbæ, as will be seen from the above resumé,
opinion is sharply divided on one main issue, as to whether the amœbæ visible
microscopically in the stools are or are not specifically identical with those
which can easily be cultivated on artificial media.
For the affirmative, Musgrave and Clegg, Lesage, Walker and Noc ; for the
negative Schaudinn, Jürgens, Viereck, Hartmann. and Werner are quoted
above.
The following are contributions to the question from the point of view of
the protozoologist : Vahlkampf 2 3
mentions that Kartulis cultivated a " dysen-
tery " amœba in a medium consisting of diluted rabbit's and pigeon's fæces
contained in open vessels, and that Kruse and Pasquale considered that
these amœbæ were not parasitic but were simply saprophytes which had
gained access to the cultures from the air.
Nägler,17 (1909), in introducing observations on the life-cycle of some
saprophytic amœbæ, says "In medicine also, an exact knowledge of the life-cycle
of amœbæ is of great importance ; it precludes such error as has arisen in the
work of Musgrave and Clegg, for example ; these authors have cultivated forms
resembling Amœba limax and have given them out as dysentery amœbæ,
whereas these cultivated forms have absolutely nothing to do with genuine
parasitic amœbæ, but belong to the limax group."
Doflein,7 (1909), after considering the various amœboid organisms which
have been described as occurring in the fæces, dwells upon the difficulty of
coming to a decision as to which of the following headings such organisms
should come under
(i) " Gelegentliche Passanten des Darms " i.e., casual visitors in the
gut or pseudoparasites : this group would include saprophytic
amœbæ swallowed in the encysted condition and excreted un-
changed2 7
(ii) Facultative parasites, and (iii), amœbæ specifically adapted to the
parasitic habit.
Recently (March 1911), Whitmore 2 8
e x a m i n e d c u l t u r e s o n M u s g r a v e ' s
medium of amœbæ from fæces and liver abscess pus obtained in Manilla. In
a preliminary note he states that he foumd these amœbæ to represent two dis-
tinct types, both of which belonged to the " limax " group ; the vegetative forms
possessed " the typical karyosome nucleus " and formed cysts with one single
nucleus. He concludes by confirming Hartmann's view that they have nothing
whatever to do with the parasitic amœbæ which occur in the gut.
Major W. G. Liston, I.M.S., in a paper as yet unpublished which he has
kindly allowed me to read in manuscript, describes two different kinds of
amœbæ which he had separated in a growth from liver abscess pus on
Musgrave's medium ; he is of opinion that types similar to both of these forms
are described by Noc as belonging to a single species.
3. NON-SPECIFIC DYSENTERIES.
Infection of the large intestine by the tubercle bacillus may give rise to
symptoms hard to distinguish clinically from chronic dysentery (Buchanan). 4
Malarial and Leishmania infections are also stated to give rise occasionally
to symptoms of dysentery (Manson). 14
Another form of the disease due to worm infections is also described by
the same author as " Verminous dysentery.'' 14
6
4. DYSENTERIES OF UNCERTAIN ORIGIN.
Apart from the members of the " B. dysenteriæ " group, various bacteria
have at times been described in causal relation to dysentery.
A virulent type of B. coli pathogenic to animals, was isolated from
dysenteric stools by Chantemesse and Widal, Arnaud and others ; streptococci
and. B. pyocyaneus have also been credited with causing dysentery. 6
Possibly dysenterigenic properties have also been attributed to several
flagellates, Lamblia intestinalis, (Bohne u. Prowazek). 2 B a l a n t i d i u m
(Hartmann)11 and Trichomonas (Billet). 1
It does not appear, however, that the claims of any of the above organisms
to rank as dysentery-producers have been established.
It is, indeed, widely recognised that many cases of dysentery occur in
which microscopical and cultural examination of the stools during life and of
pathological material after death fail to demonstrate a causal organism.
Strong2 2
r e m a r k s t h a t , ( b e s i d e s a m œ b i c a n d b a c i l l a r y f o r m s ) , " t h e r e i s a
third catarrhal dysentery which is seen occasionally in the tropics and has a
varied etiology. It is occasionally indistinguishable from amœbic dysentery."
Shiga2 1
n o t e s t h a t m a n y c a s e s o f c h r o n i c d y s e n t e r y c o m e u n d e r o b s e r v a t i o n
in which neither dysentery bacilli nor amœbæ are to be found ; these he
characterises as " subsequent diseases," presuming that the causal organisms
originally present have been eliminated from the gut, leaving unhealed lesions.
behind.
Davidson6 states that " symptoms clinically indistinguishable from speci-
fic bacterial dysentery also arise from chill, dietetic errors and mechanical, toxic
or parasitic irritants," for such cases he suggests the title " pseudo-dysentery."
Manson,1 4
( 1 9 0 7 ) r e m a r k s " w e c a n n o t e v e n s a y f o r c e r t a i n w h e t h e r t h e r e i s b u t
one disease having grades of severity or a dozen specfically distinct diseases.
included under the term " dysentery."
5. MALINGERING .
Malingerers must naturally be common in Indian Jails (Buchanan) and
dysentery offers one of the best subjects for their art.
The principal irritants used by convicts to produce or aggravate dysentery
seem to be :—
(i) Mechanical, such as, powdered glass or brick dust, iron filings, chaff.
(ii) Chemical, as aloe-juice, crushed castor or mustard seeds,
crushed marigold heads, raw garlic, (the core of the latter being
used as a suppository), coaltar, " Saji Matti" (alkaline earth used
in washing clothes) and lime.
Charts representing the departure from the mean of the average
Monthly admission rates for Dysentery and Diarrhœa in
relation to the rainfall during the years 1904–1909.
C h a r t I .
Mean of average Monthly admission rates
for Dysente
ry and Diarrhœa 32.
Mean of average monthly rainfall 6.
7
Moreover, the practice of substituting dysenteric stools for their own more
or less healthy motions is not unknown among convicts and healthy stools may
be mixed with urine and blood in order to simulate dysenteric motions.
(b) Intestinal Diseases in Bengal Jails.
In Bengal Jails intestinal disturbances account for a much larger propor-
tion of admissions to hospital and of deaths than diseases of any other single
system.
As already pointed out the term " dysentery " is a loose one ; in the early
stages of the disease, as also in chronic cases, diarrhœa is often a marked feature
and cases may be diagnosed according to the official " Nomenclature of
Diseases " as " 14. Epidemic diarrhœa" or " 540. Diarrhœa" while " 515 (1)
Enteritis " and " 515 (3) Colitis " in the returns may be taken as largely
synonymous with "11. Dysentery."
In all Bengal Jails, from 1904-1909, there were 7,333 admissions for
Diarrhœa" with 99 deaths (1.35 per cent.), the case-mortality for " Dysentery "
during the same period being 3.12 per cent. Intestinal diseases with even the
former percentage of fatalities probably include many cases which might
equally well have been returned as " Dysentery."
During the period 1904-1909 the annual average of the total number of
admissions for dysentery and diarrhœa in Bengal Jails was 3,930.2 with 102.3
deaths, as compared with a total of 13,687.3 admissions and 333.8 deaths from
all causes, so that 28.7 per cent. of all admissions and 34.2 per cent. of all deaths
were due to dysentery and diarrhœa.
The disease incidence shows a marked seasonal variation, generally reach-
ing a maximum in July (see Chart No. I).
8
As shown by Colonel W. J. Buchanan, T.M.S., there had been in 1909,
a marked and progressive decrease in the admissions for dysentery (400 per.
mille to 145 per mile) as also in the case-death-rate (5 per cent,. to 2 or 3 per
cent) in Bengal jails collectively during the previous 30 years; but there still
occur in individual jails fluctuations in the incidence of the disease, the causes
of which at present remain obscure.
(c) Dysentery in Hazaribagh Central Jail.
Over the period 1904-1909 the average maximum prevalence of dysentery
and diarrhœa in Hazaribagh Central Jail occurred, as in Bengal Jails generally,
in July (Chart No. II) and in 1910 also the "paroxysmal" July rise in the
curve is very striking (Chart No. III).
Charts representing the departure from the menu of the average
Monthly admission rates for Dysentery and
Diarrhœaadmission to the rainfall during the years 1904—1909
II.
In Hazaribagh Central Jail,
Chart II.
Mean of average Monthly admission rates
for Dysentery and Diarrhœa 32.
Mean of average monthly rainfall 5.
Charts representing the departure from the mean of the Monthly
admission rates for Dysentery and Diarrhœa in relation
to the rainfall in Hazaribagh Central Jail
during the year 1910.
Chart Ill.
Mean of average Monthly admission rates
for Dysentery and Diarrhœa 42
Mean of average monthly rainfall 4
Charts representing the departure from the mean of the Monthly
admission rates for Dysentery and Diarrhoea in relation
to the rainfall in Hazaribagh Central Jail
during the year 1910.
Chart III.
JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC
+97
+ 96
+95
+94
+93
+92
+91
+90
+89
+88
+87
+86
+85
+84
+83
+82
+81
+ 80
+79
+ 7 8
+ 77
+76
+75
+71
+73
+72
+74
+70
+69
+68
+67
+66
+65
+64
+63
+62
+61
1+60
+59
+58
+57
+56
+55
+54
+53
+52
+51
+50
+49
+48
+47
+46
+45
+44
+43
+42
+41
+40
+39
+38
+37
+36
+35
+31
+33
+32
+31
+30
+29
+28
+27
+26
+25
+24
+23
+42
+21
+20
+19
+18
+17
+16
+15
+14
+13
+12
+11
+10
+9
+ 3
+ 1
+6
+ 5
+ 4
+3
+2
+1
-1
-2
- 3
-4
-5
-6
-7
-8
-9
-10
-11
-12
-13
-14
-15
-16
-17
-18
-19
-20
-21
-22
-23
-24
-25
-26
-27
-28
-29
Mean of average Monthly admission rates
for Dysentery and Diarrhœa 42
Mean of average monthly rainfall 4
1
2
3
4
5
6
7
8
9
10
11
12
Name of occupation.
Cooks.
Sweepers.
Garden
and
agriculture.
Oil mill.
Aloe
pounding. Aloe net. Aloe twine. Cane and
bamboo.
Duree factory. Cloth factory. Printing.
Bakery.
Total No. of admissions
6
4
11
9
63
3
53
1
13
6
2
3
Average daily strength.
13
30
28
9
56
5
40
5
33
30
5
4
No. of admissions per
mille.
461
133
393
1,000
1,125
600
1,325
200
394
200
400
750
9
The following table shows the admission rate under the heading of occupations:
—
TABLE I.— Showing the admissions per mille for dysentery and diarrhæa in relation to occupation during
January-December 1910.
TABLE I.— Showing the admissions per mille for dysentery and diarrhæa in relation to occupation during
January-December 1910.
13
14
1 5
16
17
18
19
20
21
22
23
24
Name of occupation.
Blanket
factory.
Surgical
dressing Factory.
Carpenter and
blacksmith. Tailors. On miscella-
neous jail
service.
Employed in
preparing articles for
jail use or
consumption.
Hospital (sick.)
C. G. and
special gang. Wall
guards.
Convict
overseers. Under-trial prisoners. Pumps.
Total No. of admissions
4
2
2
7
10
10
6
8
6
5
12
9
Average daily strength.
39
25
10
11
27
40
47
117
19
38
10
22
No. of admissions per
mile.
102
80
200
636
370
250
128
67
315
131
1,200
409
10
11
The largest numbers of admissions occurred from among the convicts
engaged in aloe-twine manufacture (1.325 per mille), and from among the
under-trial prisoners (1,200 per mille).
The former class comprises mainly prisoners who are not in robust health
and. are unable for harder work; the latter are living under depressing condi-
tions and without any occupation; these facts might account for an increased
susceptibility to intestinal diseases.
It is noteworthy that those in closest contact with the sick showed no
special liability to the disease; sweepers gave a comparatively low admission
rate of 133 per mille while among the permanent hospital staff and the convict
sick attendants, (the latter included under column 17), no case was reported.
Drinking water for the jail is pumped from a tank near bye, and is boiled and
cooled before being distributed throughout the jail in pipes.
Even those prisoners who have freest access to unboiled water namely, the
out-door gang, (columns 3 and 24 in the table), did not show a high admission
rate.
Moreover these diseases were not prevalent to any extent in the Reform-
atory School, (28.4 cases per mille in 1910 as compared with 4,728 cases per
mille in the jail during the same year), which is situated a few hundred yards
from the jail and draws its water-supply from the same source.
Neither was there any evidence of infection through the prisoner's food
which was all served out thoroughly cooked. The strictest measures for isola-
tion and treatment or dysentery cases were systematically enforced by the
Superintendent of the Jail.
II. Methods of Observation.
In investigating the causation of dysentery as it occurred in the jail, the
following methods were adopted:
—
(a) Laboratory examination of the stools.
The stools were passed into specially-constructed tin vessels provided with
lids, the whole being sterilised before each issue. Specimens of the stools were
examined as fresh as possible and were put through the following routine, as a
rule; on six successive days
(a) Naked-eye examination. The consistency, presence of fœcal matter,
mucus, blood and pus and the reaction to litmus paper were
noted.
(b) Microscopic examination. Under a one-sixth lens the presence of
debris, of formed elements such as epithelium, leucocytes, red
blood corpuscles, of worms, worm ova and protozoa was noted.
c2
12
(c) The stools were plated on Conradi-Drigalski medium; preferably
a flake of mucus was selected for planting, after being washed
in 3-4 changes of normal salt solution. The plates were
examined, after incubation at about 37° C. for twenty-four hours
for the presence of "dysentery" colonies.
(d)
In a series of cases the stools were planted on Musgrave's medium
also in order to determine whether amœbæ could be cultivated
from them.
(b) Clinical examination of the cases.
Observation was especially directed to the following points :—(a) the
temperature, (b) the condition of the tongue, (c) the frequency of the stools, (d)
the presence of griping and tenesmus, (e) abdominal pain and tenderness, (f)
pain, tenderness or enlargement of the liver.
The agglutinative power of the blood-serum on Bacillus dysenterim
(" Shiga " and " Flexner " types) was tested in many cases and in. selected
cases repeated blood-counts were made, including enumeration of. the total red
and white cells and differential leucocyte counts.
(c) Post-mortem examination.
Post-mortem examination was made in fatal cases, with microscopic and
cultural examination of scrapings from the diseased intestine. Pieces of tissue
were removed for embedding and section.
Preliminary remarks.
Altogether 268 cases of dysentery came under observation in the jail. In
14 (4.9 per cent.) of them a bacillus of the dysentery group was isolated; in
52 (19.5 per cent.) motile amœbæ were found microscopically; in 5 cases
distinct evidence of tuberculosis of the intestine was found post-mortem.
In one of these tubercular cases motile amœbæ had been found in the
fæces during life but no lesion of the large intestine was found post-mortem
except patchy congestion and no amœbæ were detected microscopically in
scrapings from the large and small intestines. In the remaining four cases
neither bacilli nor amœbæ had been found.
In one of these cases the patient was under treatment for phthisis
pulmonalis when first admitted for dysentery; of the others, three showed signs of
active tuberculosis of the lungs on admission and one had intestinal symptoms
13
only. These four cases had from 3 to 6 previous admissions for dysentery and
diarrhœa.
The intestinal symptoms were those of obstinate chronic dysentery.
Post-mortem, the lower part of the ileum in four cases showed characteristic
tubercular ulcers, in one case, congestion only; caseating. mesenteric glands
were found in four cases.
In only one case was there ulceration of the large intestine, in the form of
a few superficial erosions of the lower rectum without specific characters.
In one case there was general miliary tuberculosis; and in four cases there
were tubercular foci in the lungs.
The following table gives an analysis of the further results of microscopic
examination of the stools.
TABLE II.— Showing the frequency of the occurrence of certain parasites and ova in the fæces.
— Trichomonas
intestinalis.
Balantidium
coli.
Lamblia
intestinalis (?).
Ankylostoma ova
in fæces or adults
found post-
mortems.
Ascaris
ova.
Trichocephalus
ova.
Oxyuris
ova.
Strongyloides
stercoralis.
Cestodes.
1
2
3
4
5
6
7
8
9
Total in 268
cases .
184
1
1
92
13
2
4
5
1
Percentage .
68.6
0.35
0.35
34.3
5
0.7
1.4
1. 8
0.35
15
(b) Characters of the stools in dysentery cases.
Apart from the finding of motile amœbæ microscopically, and the recovery
of dysentery bacilli by culture, no characters were observed in the stools which
might serve as a basis for classification of the cases into distinctly separate
types. The features of the motions seem to depend upon the grade of severity
and upon the duration of the case, rather than upon any specific action of the
causal virus.
The stools, in the acute stages, generally consist of small quantities, (1-3
'drachms), of tough muco-pus, streaked with bright red blood, the appearance
sometimes being reminiscent of a phthisical sputum; or there may be an ounce
or two of turbid abilious fluid mixed with masses, flakes or streaks of more or
less blood-stained mucus. Stools of this kind may alternate with more copious
loose fæculent motions containing mucus and blood.
As convalescence becomes established the
fæcal element in the stools
predominates, first fluid, then solid with more or less admixture of mucus.
In the chronic stages of the disease the motions often contain large
amounts of tenacious blood-stained mucus, shreds of sloughy-looking material
and blood-clots with more or less bile-stained sediment. The odour may be
very offensive but does not seem to be in any way characteristic. The reaction
of the stool is generally alkaline, seldom neutral or acid.
Microscopically the muco-sanguineous pus is found to consist of leucocytes
mostly of the polymorphonuclear variety, red blood corpuscles and a small
proportion of epithelium.
In stained preparations the appearance often resembles that of a film of
abscess pus, many of the leucocytes containing coli-like bacilli.
The looser fæculent motions consist of bile-stained granular debris in
which partially.digested vegetable cells and a large proportion of epithelium
may generally be recognised.
The microscopic characters of the amœbæ and the results of cultivation of
the stools will be described later.
( c) Clinical examination.
The cases do not seem to present any groups of features which might be
definitely correlated with the laboratory findings, and the classical distinctions
between the "bacillary" and "amoebic" types of dysentery were not observed
clinically.
No group of cases occurred as a distinct epidemic; bacillary and amœbic
cases as well as those of "uncertain origin" seemed to occur quite erratically.
Some further facts from the collected records of these cases are given in
table III.