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THE LIBRARY

OF

THE UNIVERSITY

OF CALIFORNIA



PRESENTED BY

PROF. CHARLES A. KOFOID AND

MRS. PRUDENCE W. KOFOID



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AMCEBIC OR TROPICAL
DYSENTERY

ITS COMPLICATIONS AND TREATMENT



BY



W. CARNEGIE BROWN, M.D.

Member of the Royal College of Physicians



ILonDon

JOHN BALE, SONS & DANIELSSON, Ltd.

OXFORD HOUSE

83-91, GREAT TITCHFIELD STREET, OXFORD STREET, W.



1910






PREFACE.

Since Baly chose dysentery as the subject for the Goulstonian
Lectures, sixty years ago, there have been many revolutionary
changes- in our conceptions of disease. At that time dysentery was
still prevalent in Great Britain, smouldering for the most part in
the slums and hovels of the poorer classes, but occasionally blazing
out into virulent epidemics which attacked all sections and grades
of society. Thanks to hygienic reform and progress, domestic
interest in the condition has considerably narrowed ; for, although
infection still lurks in the western districts of Scotland and Ireland,
and lingers with a strange persistence in many of our most efficient
lunatic asylums, dysentery has been practically banished from the
general life of England.

From an Imperial and Colonial point of view, however, the
study of this disease still remains a subject of pre-eminent
importance. The recent development of industrial and agri-
cultural activities in our tropical possessions and the increased
facilities for communication have resulted in an enormous demand
for the services of Europeans, and within the last thirty years the
white population has multiplied five-fold. Of the pro.tean climatic
diseases which they have still to face, dysentery is second in
prevalence only to malaria, and from all classes and races it annually
claims an appalling number of victims.

The discovery that dysentery itself is not a single disease may
be regarded as one of the most remarkable advances in modern
medical science ; for, although in medicine it is impossible to claim
that any theory of disease has been immutably settled, or that the



r-:«-»r- rf^M»^KS/9



IV. AMCEBIC DYSENTERY

final word has been spoken, our conception of amoebic dysentery
as a distinct and specific affection is definite and assured, and the
pathology of the disorder is now a chose jugee. The literature of
the subject, already very extensive, is rapidly increasing, and almost
every month important additions are being made to our knowledge.
The very scope and volume of these contributions is indeed so great
that it tends to diminish their practical value ; for, published as they
are in all languages and in all parts of the world, and scattered
through an enormous number of scientific journals, most of them
are accessible only to those who make a special study of the
subject. It is believed, therefore, that a general survey of the
information which has recently been acquired with regard to
amoebic dysentery and other protozoan infections of the human
intestine may not be devoid of interest and utility.

For an accurate appreciation of the pathology of amoebic
dysentery, a knowledge of the cardinal facts in the life-history of
the specific organisms and of their relations to other intestinal
protozoa is essential ; and it is endeavoured in these pages to set
forth as clearly as possible the outstanding features in the natural
history of the entamoebae. But no attempt has been made to give
a complete account of this important group, or to trespass on
the domain of pure zoology, and only those events in the develop-
ment and reproduction of the parasites which have a direct bearing
on amoebic dysentery have been fully considered. It is not pre-
tended that the biological section is more than a narrative of the
prominent phenomena for which a special relation to a distinct
morbid process is claimed ; and, as far as possible, the intricacies
of detailed zoological description, which occasionally tend to obscure
medical issues, have been avoided.

The book is, indeed, chiefly intended for the practising physician,
and its principal aim is to emphasize the necessity of early diagnosis



PREFACE V.

and to lay down precise and comprehensible directions for the
treatment of the various clinical types of amoebic dysentery. An
attempt has been made to take into account the varying conditions
under which the disease may have to be treated, and special regard
is paid to the remedial measures which are best suited to the require-
ments of warm climates. The object of the work will be more than
achieved if the instructions for the general management of cases
and for the selection and use of suitable remedies prove of practical
value and assistance.

I am indebted to Mr. A. Engel Terzi for the care and artistic
skill which he has devoted to the illustrations, and to Miss May
Sinclair for many valuable suggestions and much helpful criticism
during the revision of the proofs.



32, Harley Street, London, W.
August, 1 9 10.



CONTENTS.



CHAPTER I.

PAGE

Introductory 3

CHAPTER II.
History and Literature of Amoebic Dysentery 7

CHAPTER III.
Epidemiology and Geographical Distribution 24

CHAPTER IV.
Classification and General Relations of Protozoa to Intestinal Diseases ... 41

CHAPTER V.
The Entamoebae of the Human Intestinal Tract 44

CHAPTER v.

The Entamoebae of the Human Alimentary Tract — Morphology and Struc-
tural Comparison 5°

CHAPTER VII.
The Entamoebae of the Human Alimentary Tract — Reproduction 64

CHAPTER VIII.
The Entamoebae of the Human Alimentary Tract — Cultivation 71

CHAPTER IX.
Other Protozoan Infections of the Human Alimentary Tract 79

CHAPTER X.
The Symptoms of Amoebic Dysentery 93

CHAPTER XI.
Diagnosis 108

CHAPTER XII.
Morbid Anatomy 1^9



Vlll. AMCEBIC DYSENTERY

CHAPTER XIII.

The Case for the Pathogenicity of Entamoeba Histolytica

CHAPTER XIV.
The Causes of Amcebic Dysentery

CHAPTER XV.
Hepatic Abscess

CHAPTER XVI.
Other Sequelae of Amoebic Dysentery

CHAPTER XVII.
The Prophylaxis of Amoebic Dysentery

CHAPTER XVIII.
The Treatment of Acute Amoebic Dysentery

CHAPTER XIX.
The Treatment of Chronic Amcebic Dysentery

CHAPTER XX.
Diet in Chronic Amoebic Dysentery

CHAPTER XXI.
The Treatment of Amoebic Dysentery by Drugs

CHAPTER XXII.
Local Medication

CHAPTER XXIII.
Surgical and other Methods of Treatment

CHAPTER XXIV.
The Treatment of Amoebic Abscess of the Liver— Prophylaxis

Index



PART I.— GENERAL.



AMCEBIC DYSENTERY.



CHAPTER I.
Introductory.

For many centuries, several different infections, similar in their
clinical manifestations, but distinct in specific character, have been
described by the single term Dysentery. The symptoms common
to these disorders are definite and characteristic, and clearly
separate the condition from other morbid processes of the
alimentary tract ; but, within the last few years, the suspicion —
originally raised by marked variations in clinical type — that
dysentery might itself be more than a single pathological unit,
has been fully confirmed.

The number of individual diseases which may rightly be com-
prised in the group is still uncertain, but at least two have now
been definitely differentiated, and the pathogenic nature of the
micro-organisms in which they originate has been completely
established. Of these infections, one is protozoan, and the other
bacterial ; the varieties of dysentery, of which they are respectively
the causes, being known as amoebic and bacillary.

Strong claims have been advanced for the further subdivision
of these types, and especially for the recognition of additional forms
of protozoan dysentery ; but although the evidence which has been
adduced is highly significant, it is at present insufficient to warrant



4 AMCEBIC DYSENTERY

a new classification, or to incriminate other microbial organisms
as pathogenic. There is, however, abundant proof of the etio-
logical relation of the rhizopod — Amceba dysenterice (Councilman
and Lafleur), Entamoeba coli (Casagrandi), E. histolytica
(Schaudinn) — to amoebic dysentery ; and of the connection
between one or more species of bacteria — of which the variety
known as Shiga-Kruse is the most familiar — and the bacillary variety
of the disease.

It is with the first of these infections — Amoebic Dysentery — that
this work is principally concerned ; and an endeavour will be made
to describe the biological relations of the organism, the history of,
its discovery, the epidemiology and distribution of the disease, the
pathological results of amoebic infection, and the most effective
methods of prevention and treatment.

DESCRIPTIVE DEFINITION.— Amcebic Dysentery is a
disease which originates in penetration and subsequent destruction
of the intestinal walls by a specific protozoan micro-organism —
Entamoeba histolytica ; the lower segment of the alimentary tract,
viz. : — the colon, sigmoid flexure and rectum being the favourite
sites of invasion. The signs of acute infection are fever, sickness,
pain, and tenesmus, with frequent calls to stool. The dejecta are
scanty, and consist principally of mucus and blood.

The commencement of amoebic dysentery is, however, generally
very insidious, and active dysenteric symptoms seldom develop for
some time after infection. The course of the disease is protracted,
and it has a marked tendency to recurrence and chronicity. The
later stages are often characterized by toxaemia ; and, not infre-
quently, they are complicated by hepatic suppuration.

NOMENCLATURE. — Alternative Terms : Tropical
Dysentery — Amgebiasis — Amcebic Enteritis — Amcebic Colitis
— Amobenruhr — Dysenterie Amibienne — Dysenterie a amibes.



INTRODUCTORY 5

As infection by a specific micro-organism of the Amoeba family
is not only the cause of a definite train of symptoms but also serves
to distinguish the type of disease, the term Amoebic Dysentery
is, perhaps, more applicable than any other title. It is eminently
desirable that a disorder of widespread prevalence should be known
by a distinctive and practical name, and one which is readily
comprehensible by laymen as well as by physicians. Amoebic
Dysentery fulfils these indications satisfactorily ; and it has, besides,
the conspicuous advantage that it has already secured general
adoption.

Considerable confusion has, however, arisen in the nomenclature
of the disease by a difference of opinion as to the use of the term
" Tropical " dysentery. By many writers that name is applied^
irrespectively of the nature of the infection, to any variety of
dysentery which has originated in the tropics ; while by others its
application is strictly confined to the amoebic type of the disease.
Amoebic dysentery is, indeed, regularly described by many
authorities as " Tropical " dysentery, although the reference is to an
infection contracted in a cold climate, and although the patient
may not have been in the tropics.

This indiscriminate application of the term " Tropical " is some-
what unfortunate. Bacterial dysentery is common in the tropics ;
indeed, although it has become endemic in many temperate regions,
it is, essentially, a tropical disease ; and many, if not most, of the
European invalids who return from warm climates suffering from
a chronic flux of mucus and blood exhibit no trace of amoebic
infection. Amoebic dysentery, on the other hand, is by no means
a distinctively tropical affection ; it is prevalent in most sub-tropical
countries, and it is of common occurrence in many districts of the
temperate zone.

Strictly speaking, therefore, " Tropical dysentery" is an inappro-



6 AMCEBIC DYSENTERY

priate title ; but greater confusion undoubtedly results from its
employment in a geographical sense than by its retention as a
synonymous term for amoebic dysentery. In the latter relation,
the name "tropical" has, to a certain extent, been sanctioned by
custom ; and, provided that it is applied only to cases of amoebic
dysentery, there can be no serious objection to its use.

Amcebiasis — a word recently introduced to denote amoebic
disease generally — has been adopted by several authors as an
alternative title for amoebic dysentery. In this sense, however,
it is vague and unsatisfactory ; it does not express the dysenteric
state, and it should be confined to cases in which symptoms other
than those of dysentery have been produced by amoebic infection.
Further confusion is caused by the fact that " amoebiasis " is
often applied to the condition in which non-pathogenic amoebae
are harboured in the intestine without hurt to their host ; but
its use in this sense is unjustifiable and misleading.

On the other hand, " amoebiasis " accurately and conveniently
expresses a morbid state in which amoebic infection is followed
by symptoms of which dysentery is not a predominant feature.
Such an event is unusual ; but hepatic and cerebral amoebic
abscesses, and other consequences of infection, without precedent
dysentery, are by no means unknown.

The term Amcebic Colitis is sometimes employed by physicians
who find a distinction between colitis and dysentery. In rare
instances the development of pathogenic amoebae may be arrested
before the ulcerative stage of inflammation is reached, and
"amoebic colitis" would then be descriptive of the pathological
condition. But amoebic colitis is, after all, only a stage of
dysentery, and a multiplication of names for a single disease is
undesirable.



CHAPTER II.
History and Literature of Amcebic Dysentery.

Although various protozean organisms had previously been
described as occasional habitants of the human alimentary tract,
the history of amoebic dysentery definitely begins with the dis-
covery by Lambl of a rhizopod in intestinal mucus, taken from a
Jewish child, who died of infantile diarrhoea at the Kinder Spitale
in Prague, in 1859. This organism he regarded as a monad —
the term then generally used for unicellular protozoa — and his
description states that it measured '009 mm. by '016 mm. At
rest, it was roughly spherical in shape, but when in motion the
body became elongated, and the animal progressed by throwing
out club-shaped pseudopodia, which were homogeneous with the
body substance. Lambl further noted the characteristic mole-
cular vibration of granules in the protoplasm, which, he stated,
was most active near the roots of the pseudopodia. Vacuoles were
also seen in the body substance, and, in some specimens, delicate
nuclear vesicles were visible. The movements, both protoplasmic
and granular, were active at first, but within a few hours after
the collection of the intestinal mucus they gradually ceased.
These organisms were subsequently demonstrated by the same
observer in many other cases of dysenteric diarrhoea.

Lambl does not appear to have received the credit which he
deserved for these important observations. It is generally stated
that he attached no pathological significance to the presence of



8 AMCEBIC DYSENTERY

amoebae, but that is incorrect. If his original paper is consulted,
the following words will be found : "It is an established fact that
minute organisms, which appear to be closely related to the
rhizopoda, are present in the human intestinal canal, and their
importance in regard to the concomitant pathological processes in
children should certainly not be under-rated." ^ Not only, there-
fore, did Lambl first describe the morphology of an intestinal
amceba, but he demonstrated the organism in association with a
definite form of disease, and although he naturally hesitated to
express the view that pathogenicity had been proved, he clearly
realized that it was probable.

Lambl's researches were published in a somewhat inaccessible
series of reports, and, although noted ^ by Leuckart (who also
found parasitic amoebae in the human intestine), his paper failed
to reach other investigators. In India, Lewis, while examining
cholera dejecta in 1870, observed living amoebae, but attached no
importance to their presence, and although his description of the
organisms is full and distinctive, it is not clear that he even
recognized them as protozoa. He seems rather to have regarded
them as some variety of normal cell, the morphology and develop-
ment of which resembled that of an ordinary leucocyte. There
can be little doubt, however, that if Lewis had been aware of
Lambl's paper, he would have taken a different view, and would
have made further inquiry into the subject of amoebic infection.

Five years later, intestinal amoebae were again demonstrated
and described by Dr. F. LOSCH, clinical assistant to Professor
Eichwald, of St. Petersburg. The patient was a young peasant



* Lambl, " Beobachtungen und Studien aus dem Gebiete der pathologischen
Anatomic und Histologic." Prague: i860, Fricdrich Tempski.

* F. Leuckart, " Die menschlichen Parasiten." 1863.



HISTORY AND LITERATURE OF AMCEBIC DYSENTERY 9

of Archangel, who was suffering from dysentery which, after
persisting intermittently for two years, ultimately proved fatal.
During his illness, amoebae were repeatedly found in the mucus
passed with the dejecta ; but just before death, which was actually
the result of a terminal pleuro-pneumonia, the organisms entirely
disappeared. At the post-mortem examination, however, they were
shown to be present in enormous numbers in the intestinal contents,
and in numerous ulcers on the mucous membrane of the colon and
sigmoid flexure.

LusCH, who had seen Lambl's paper and was much impressed
by his researches, fully appreciated the pathological importance of
the discovery. But, clear as was the evidence, it was supplied by
a single instance of the disease, and was still insufficient to establish
a claim for pathogenicity. He accordingly limited himself to the
conclusion that a superimposed infection of amoebae had possibly
only aggravated an ordinary case of ulcerative colitis. His own
belief is, however, clearly indicated by the fact that he undertook
experiments to test the biological relations of the organisms.
Some mucus containing amoebae was injected into the rectal
cavities of four dogs, and in one case this attempt to reproduce
the disease was successful, for dysentery supervened, and amoebae
were recovered from the dejecta. The infected dog, when killed,
was found to be suffering from extensive, although superficial,
ulceration of the lower part of the colon.

There can be no doubt that LOsch's case was a typical instance
of amoebic infection, and his careful study of the condition,^ illus-
trated as it is by a large number of excellent plates, which show
the development of the amoeba and its power of ingesting red

^ F. Losch, " Massenhafte Entwickelung von Amoben im Dickdarm," Virchow's
Archives^ Ixv., 156.



lO AMCEBIC DYSENTERY

blood corpuscles, remains one of the best, as it is the first important
contribution to the literature of amoebic dysentery.

Closer attention was naturally directed to the subject of intes-
tinal amoebae by the publication of Losch's report, and during the
next few years numerous papers on the development and life-
history of parasitic protozoa appeared in medical and scientific
journals. Among the more important were those of Grassi,* who,
so early as 1879, showed that intestinal amoebas passed through a
cystic stage, and that, when the conditions of life were unfavour-
able, cysts were formed in greater numbers. He found intestinal
amoebae in healthy persons as well as in those affected by dysentery,
and he accordingly opposed the theory advanced by LOSCH that
they might be the cause of the disease.

About the same time, amoebae were reported by Leuckart ^ as
having been found in healthy human dejecta, by Perroncito ^ as
occurring in the contents of an otherwise normal colon, and by
SONSINO ^ (who, however, did not regard them as causative) in the
intestinal mucus of a child who died of dysentery at Cairo.

From that city also came the next important addition to the
knowledge of the subject. While examining sections made from
the intestinal walls of victims of the cholera epidemic of 1893,
Professor Koch observed a species of amoeba embedded in the
tissues. This he regarded as possibly pathogenic, but, being fully
occupied with bacteriological work, he was unable at the time



* Grassi, " Die protozoi parasiti e specialmente di quelle che sono nell'uomo,''
Gazeta Med. Italiatm, 1879, P- 445 '■> and other papers in the Proceedings of
the Societa Italiana di scientia naturale, Milan, 1882 ; and in the Aiii de R.
Accadejnia di Lincei, 1888.

' Leuckart, " Die Parasiten des Menschen." Leipzig, 1879.

•^ Perroncito, " I Parasiti." Milano, 1881.

' P. Sonsino, " Davidson's Hygiene and Diseases of Warm Climates.'' 1893.



HISTORY AND LITERATURE OF AMOEBIC DYSENTERY II

to investigate the question, and he asked Dr. S. Kartulis to
determine, if possible, whether the organism had any definite
relation to a morbid process.

During the next two years, Kartulis examined, post mortem, a
large number of fatal cases of intestinal disease, and, as a result of
his observations, published ^ several papers in which he stated that
amoebae were invariably found in Egyptian dysentery ; and he
further recorded his belief that they were undoubtedly the patho-
genic agency in that disease.

In a consecutive series of 150 autopsies, which he made at the
Greek and Arab hospitals in Cairo, Kartulis found amoebcc in
every instance in which there had been marked dysenteric
symptoms, w^hilst in patients who had died from other causes they
were never once discovered. He thought that in severe dysentery
the amcebic infection was excessive, and that in mild cases it was
slight, and he claimed that a direct relationship between the
number of organisms and the intensity of the symptoms could
always be demonstrated.

Of twelve fatal cases of dysentery in which sections of the
colon were made, amoebae were found in every one ; while similar
specimens prepared from the intestines of thirty persons who had
died of typhus, tuberculosis, enteric fever, and Bilharzia disease,
contained not a single amoeba. Kartulis was unable at the time
to cultivate the amoeba, or to reproduce the disorder in guinea-pigs
and rabbits ; but his experiments in this direction were on a
scale insufficient to give reliable results.

* Kartulis, " Ueber Riesen-Amoben bei chronischer Darmentziindung der
Aegypter," Virchow's Archives^ 1885, xcix., 145.

Ideitty "Zur Aetiologie der Dysenteric in Aegypten," Vtrchow's Archives, 1886,
cv., 521.

Idetn, " Einiges iiber die Pathogenese der Dysenteric," Centralbl. ^iir Bakt.,
1891, ix., 365.



12 AMCEBIC DYSENTERY

There can be no question of the importance of those observa-
tions, and of the influence which they exercised on the views then
current as to the nature of the disease. Since the days of Hippo-
crates, dysentery had been regarded as a "phlegmonous" or
" sthenic " inflammation ; and the proper method of dealing with
it was believed to be depletion and the continued action of
depressant drugs. The introduction of ipecacuanha had lessened,
to some extent, the appalling mortality which had long been con-
sidered inevitable, but which, it was now realized, was a direct
consequence of treatment. Still, although blood-letting to faint-
ness and huge doses of calomel had given place to more rational
remedies, the conception that dysenteric symptoms might originate
in various causes, and that at least one variety of dysentery was
parasitic, came as a revelation. The ultimate establishment of
amoebic dysentery as a distinctive disease is largely due to
Kartulis's pioneer work in Egypt ; and he may justly claim
the greatest share of the credit for this notable advance in medical
science.

Kartulis has elaborated and confirmed these researches by
many further observations. In 1887 he pointed out the definite
association of Amoeba coli with hepatic suppuration ; and he has
since published ^ numerous important papers on amoebic dysentery
and its sequelae. The recent article, " Die Amoben Dysenteric,"
in KOLLE and Wassermann's " Handbuch " — an excellent and
comprehensive review of the subject — is from his pen.

Kartulis's observations were promptly confirmed by Hlava^^

" See among others: (i) " Ueber weitere Gebreitungsgebiete der Dysenterie-
Amoben,'' CentralbL f. Bakt. unci Parasitenkunde, 1891, ix. ; (2) "Ueber patho-


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