Reflections on my studies of the effects of sulphonamide drugs in bacillary dysentery in Egypt, 1943-1944
Authors: J G Scadding
Journal: Journal of the Royal Society of Medicine (2006)

This is an attempt to recall and set down briefly my recollections of the studies of the use of sulphonamides in bacillary dysentery which I made in 1943 and 1944 during my service in the Royal Army Medical Corps in Egypt.1-3 I end with a note on the relevance of this experience to my membership of the MRC Streptomycin Trials Committee in 1946 onwards.

I will start by outlining my background at the time of the dysentery studies. I had been in Egypt for 3 years at the time of the studies. I was officer-in-charge of the medical division of the 19th British General Hospital, situated at Fayid, on the shore of the Great Bitter Lake (which lies in the course of the Suez Canal), half-way between Port Said and Suez. The responsibilities of this posting can be compared with those of a combined administrative and clinical director of a department of medicine (including all specialties) in a large general hospital. We were probably the largest British military hospital in Egypt, with 1800 beds for British and allied troops, and 1000 for German prisoners of war. We were at the centre of a large number of base units, not only army, but also air force and navy.

Sited as we were in the desert, miles away from Cairo, Alexandria or other large towns, we were left to get on with our job of dealing with the medical problems of a large and changing population of troops from all over the world, with very little interference from ‘higher-ups’. In addition to myself as officer-in-charge, the medical division consisted of two medical specialists and a limited number of general duty officers; usually about three, but reduced in the very busy summer of 1943 to one-and-a-half, one being shared with the surgical division. Our division would typically have to deal with 700 or even more patients at any one time, all acute admissions.

I was required to produce quarterly reports of the activities of my medical division, and have preserved copies of them. Looking at the reports for the periods in 1943 and 1944 in which I did the ‘sulphonamides in bacillary dysentery’ studies, I find that in the 3 months July to September 1943 we had 486 cases of dysentery among a total of 3509 admissions. In 1944 there were 590 cases among 3774 admissions. This indicates the background of heavy clinical responsibilities with which any attempt at scientific investigation was competing. At one time or another we had to deal with nearly every acute infectious disease then known. The only notable exceptions were yellow fever and cholera, which did not occur in our area. Small-pox and plague appeared occasionally, as did outbreaks and sporadic cases of enteric fevers (typhoid and paratyphoid) and diphtheria. Occasional outbreaks of the infectious diseases then prevalent in childhood in the West (measles, rubella, chicken pox, etc.) occurred among troops coming in from other areas, notably Ceylon.

The story of sulphonamides in the treatment of bacillary dysentery, as I saw it, seems in retrospect to be a good illustration of the way in which the introduction into practice of a therapeutic procedure on the basis of a priori theoretical considerations, without a proper clinical trial, may lead to entrenched ‘clinical impressions’ that are both erroneous and difficult to displace.​displace.



Figure 1



When I arrived in Egypt in May 1941, my experience had been in general medicine with a special interest in respiratory disease, with little or no experience of diseases prevalent in tropical areas. In February 1941 I had attended a course on tropical diseases in Liverpool, which, as one who had myself been concerned with postgraduate medical education, I thought of high quality; but I can recall no mention during the course of the possible use of sulphonamides in dysentery. Sulphonamides had been in clinical use for no more than 5 years. Sulphanilamide, the first sulphonamide generally available, had been found really effective only against haemolytic streptococcal infections, notably puerperal fever. The first sulphonamide with wider antibacterial activity, sulphapyridine (M&B 693) had become available about 1937-1938.

At that time, pneumococcal lobar pneumonia was an important cause of death in previously healthy young people, and I had been concerned in attempts to assess the value of a recently introduced anti-pneumococcal serum prepared in rabbits in this disease (sera prepared from horses had been widely investigated with equivocal results, and had been largely abandoned because of the frequency of serum reactions). The lack of any immediately obvious effects of the anti-pneumococcal serum on the course of pneumococcal lobar pneumonia, with the consequent difficulty of designing a study in which any small difference might be demonstrated, contrasted with the obvious effect of sulphapyridine in such cases. This led us to abandon the study of the serum treatment and the adoption of sulphapyridine as the accepted treatment for pneumonia of this bacterial type.

Bacillary dysentery was among the most frequent diseases we had to deal with in Egypt. Its severity varied widely (from many mild infections to some that were very severe and dangerous), and it was attributable to a wide range of bacterial varieties. When I arrived, the standard treatment was, in effect, supportive care with fluids only. Some probably harmful procedures were still sometimes advocated; for instance, there was even a residue of the idea that saline purgation ought to be helpful by ridding the bowel of the infective agent. I cannot remember when or in what form the official recommendation of sulphaguanidine as a more or less ‘specific’ treatment for bacillary dysentery appeared. The general message was that sulphaguanidine was the drug of choice for the treatment of bacillary dysentery because it was poorly absorbed, persisted in high concentration in the large gut (where it was active against coliform organisms), and was almost free from the sorts of unfavourable systemic effects on the blood, bone-marrow and kidneys that the absorbed sulphonamides might cause.

Initially, however, sulphaguanidine was in short supply, and it therefore had to be reserved for severe cases of bacillary dysentery. The result was predictable: even those of us who retained our critical faculties but nevertheless followed instructions to use the drug tended, when we had prescribed sulphaguanidine for a man with severe dysentery, to attribute a favourable course of the disease to the sulphaguanidine. And if the patient died, we wondered whether he might have recovered if the drug had been given earlier in the course of the disease. Accordingly, when sufficient supplies of sulphaguanidine became available, it became established as the standard, reputedly ‘specific’, drug for bacillary dysentery.

Several people are on record as having doubted this dogma, claiming that absorbable sulphonamides (sulphapyridine, sulphathiazole) and even the simple sulphanilamide (see citations in reference 1) were at least as effective as sulphaguanidine. There is a note in my report for April-June 1944:


‘Capt. Schwartzman who has been in charge of the African section, has been using various sulphonamide drugs in the treatment of bacillary type dysentery, and has concluded that sulphapyridine gives a prompter response than sulphaguanidine and is well tolerated by African troops’.