THE ROSS INSTITUTE INFORMATION AND ADVISORY SERVICE THE INFLAMMATORY DISEASES OF THE BOWEL

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THE ROSS
INSTITUTE
INFORMATION AND
ADVISORY SERVICE

BULLETIN No. 9

AUGUST, 1970

THE INFLAMMATORY
DISEASES
OF THE BOWEL

Published by THE ROSS INSTITUTE
THE LONDON SCHOOL OF HYGIENE AND TROPICAL MEDICINE
Keppel Street (Gower Street), London, WC1E7HT

INFORMATION AND ADVISORY SERVICE

HE primary object of the Ross Institute is the prevention of
disease in the tropics. In the course of working towards this
end it has become apparent that the co-operation of industry
is essential if rapid progress is to be made. Fortunately, this co-operation
has never been lacking, for those responsible for directing tropical
industry were quick to appreciate the immense value to them of healthy
labour and have therefore been among the strongest supporters of the
Ross Institute since its inception.

T

For this reason the Ross Institute has made it an important matter
of policy to keep tropical industry informed of the progress of medical
knowledge, and of the practical methods by which the greatest benefit
may be obtained from its application. This series of bulletins, which
have been specially written for non-medical people, is one of the means
by which this information is made available; other publications are issued
from time to time and a list of those now current will be found on
page 23.
The Ross Institute invites all those whose work is connected
with the tropics to refer to it on any matter concerned with health
or welfare in tropical countries. The Director and his staff will answer
as promptly and as fully as possible all inquiries and requests for advice.
COMMUNITY HFALTH cell
47/1, (First ;
. Marks Road

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ROSS

AND

IN S TITU TE ;1 I N FO RM ATION

ADVISORY

SERVICE

Bulletin No. 9
Revised August, 1970
(Originally issued March, 1955; revised September, 1959, February, 1965;
rewritten June, 1969)

The Inflammatory Diseases of
the Bowel
By the very nature of the dramatic symptoms which they present,
the inflammatory diseases of the bowel have claimed the attention
of man since the days of Hippocrates. Though it is now recognised
in all countries that these are diseases of filth, flies and food or, in
technical language, of an insanitary environment with the associated
polluted water sources and contaminated food, the drama remains to
the public in the occasional unheralded epidemics of cholera and to the
individual in the mundane occurrence of dysentery so well depicted in
a few words by a Dutch physician in Java in the 17th century as ‘an
ulceration of the intestines with a perpetual purging, at first mucous,
and afterwards bloody and lastly purulent, with intolerable pain and
griping of the belly.’
Supreme effort by national and indeed international health
organisations render outbreaks of cholera controllable but not before
numbers of people have contracted the disease and many have died.
Prevention of the occurrence of the enteric or typhoid group of intes
tinal fevers is best maintained by the purification of centralised water
supplies or in the individual by inoculation with the well-known TAB
vaccine. The dysenteries, a miscellaneous group of inflammatory
infections of the bowel, remain to a great extent uncontrolled throughout
those countries in which climatic conditions at some time of the year
favour the transmission of these diseases—uncontrolled, yes! but not
uncontrollable, if man so chooses.
The Intestine
The alimentary tract of the human body is a muscular tube
commencing at the throat as the gullet which conveys food and fluid
to the sac-like dilation or stomach; then follows some 21 feet of tortuous
and freely movable small intestine with a diameter in the adult of 1.5
inch ; this opens into the large intestine of considerably greater
diameter and 5 feet in length which terminates at the anus. The stomach
and small and large intestine together with the liver are the major organs
filling the abdominal cavity ; this is separated from the cavity of the
chest, containing the heart and lungs, by the muscular diaphragm.
(Figure 1.)

3

Fig. 1

THE MAJOR ORGANS
WITHEN THE
ABDOMEN
A
B
C
D
E

Liver
Stomach
Small Intestine
Large Intestine
Diaphragm

The internal lining membrane of the small bowel performs the
double function of (a) secreting various ferments to assist in the digestion
of the contained food and (6) absorbing the nutrient elements from the
digested food ; this absorption occurs mainly in the small intestine.
The very fluid residue passes into the large intestine ; here the interior
lining is designed to absorb the excess w'ater and so concentrate in bulk
the waste material and store it until voided. The contents of the bowel
are moved along by rhythmic muscular contractions of the bowel itself
which have the effect of a continuous succession of1 travelling squeezes’;
when these become excessively active, griping pain is felt. In the large
intestine mucus is secreted by the lining membrane to lubricate and so
facilitate the onward passage of the now more solid content of the
intestine.
Whereas the upper part of the intestinal tract is relatively free
from bacteria, the contents of the large intestine favour the propagation
of an enormous number of a wide variety of organisms. There is now
evidence that these bacteria may take an important part in the synthesis
of vitamins which are essential to the general processes of the body.
It is obvious that any inflammation or ulceration of the lining
membrane particularly if extensive, must have a profound effect on
health through (i) interference with the assimilation of nutrients and
(ii) absorption of the toxic products of the bacteria causing the inflam
mation.
Carriers

A feature of the inflammatory diseases of the bowel is the presence
in the voided faeces of the organisms which are the cause of the illness ;
they come from the inflamed or ulcerated lining membrane of the bowel ;
they are virulent. In other words, the discharges from the sick person
are highly infective to others.

4

As the patient overcomes his illness and enters convalescence
the inflammatory foci in the bowel subside and heal ; the causal
organisms gradually decrease in numbers until eliminated.
This
subsidence process is gradual and may last many weeks after the patient
feels relatively fit ; during this time he or she continues to be infective
to others and is a convalescent carrier. Occasionally after acute illness a
patient does not recover and the disease may become chronic but
accompanied by periodic exacerbations. In a small proportion of people
who have virtually recovered from illness, small foci of ulceration persist
almost indefinitely: such persons are chronic carriers.
Some people become carriers without ever suffering from symptoms
of disease.
Adequate treatment with modern drugs curtails the spread of
inflammation of the bowel by killing the infecting organisms ; healing
occurs fairly quickly in most instances, the period of convalescence is
shortened and a persistence of the ‘ carrier ’ state is obviated.
PERSISTENCE OF THE CARRIER STATE IN SOME
BOWEL DISEASES
Bacillary
dysentery

Cholera

Typhoid
fever

Tendency to indifferent
recovery and chronic
disease ...

No

No

Presence of carrier state:
(i) during illness

Yes

Yes

Yes

(ii) during convalescence

May be
weeks

(iii) after apparent re
covery

Sufficient
to keep the
infection
going
between
outbreaks

May be
weeks, oc
casionally
longer

Up to 10
days, oc
casionally
longer

Amoebiasis

Occasional Frequent

Yes
May be
many
months, oc
casionally
years

ACUTE DIARRHOEAL DISEASE

Diarrhoea (excessive looseness of the bowels) is the cardinal sign of
most infectious enteric diseases. It is most frequent in children under
five years of age among whom occur most of the deaths attributed to
these infections. Where acute enteric infections are well controlled the
infant mortality is generally less the 30 per mille live births but where
these conditions are common the infant mortality usually exceeds
100 per mille.
S

Some enteric infections such as cholera, typhoid and dysentery are
separable from the other diseases of the bowel because they arc
characterized by particular epidemiological and clinical features. The
major form of enteric infections, however, is that which manifests itself
as ‘acute diarrhoeal disease’. This condition is a clinical entity which is
believed to have its basis in bacterial infection and Shigella is accepted
as its most common cause. Other enteropathogenic organisms may also
cause it but more often than not no definite infectious agent can be
identified. In spite of this, the spread of the condition in communities and
families and its diminishing incidence with increasing age all clearly
point to infectious origin.
Perhaps the mildest infection is the so-called acclimatization
diarrhoea, common in Egypt, India and the East and known by some
local name such as Gippi-tummy; minor constitutional reaction is
associated with six to ten evacuations in 2+ hours over a period of a few
days; blood and mucus may be seen in the stools.
The treatment of these cases aims at the eradication of the causal
organisms, and the replacement of the fluid and salts lost to the body
through the diarrhoea. The management of dehydrated patients
involves the intravenous administration of correctly balanced solutions
of certain sodium and potassium salts, but to do this effectively and
safely special training is required.

CHOLERA
Cholera is an acute intestinal infection which in former times
spread periodically along the trade routes from Asia to Europe and
America. Then it was confined for several years to Bengal, Burma and
China and its incidence there was diminishing so that hopes of its
eradication were being entertained. Recently, however, the El Tor
variety of cholera became established in Sulawesi (the Celebes) and from
there spread across Asia to Taiwan and Korea in the east and to the
Caspian and Euphrates in the west. Overcrowding and insanitary
conditions combined with poor sewage and waste disposal practices
favour the spread of cholera.
Transmission
Man is the sole source of the infection and he is responsible for its
dissemination. A typical case of cholera passes about 4 gallons of stool
and he vomits copiously. As both his vomit and his stool teem with the
causal vibrios he is capable of polluting a large area if he is not promptly
isolated. Asymptomatic infections occur about five to ten times as
frequently as overt cases and, though they secrete considerably fewer
germs for shorter periods, their numbers and their freedom of movement
make them a serious menace to public health. At one time carriers
were considered unimportant but they are now thought to be responsible
for keeping the infection going between outbreaks. Water and food
become contaminated by soiled hands or utensils, or by flies, and then

6

act directly as infecting agents. The initial wave of a cholera epidemic
regularly starts from polluted water and then spreads by contaminated
food or drink, by soiled hands, flies, etc.

The Illness
The severity of cholera varies from infections producing no clinical
signs to those in which death occurs soon after onset. The majority of
overt cases are severe and start suddenly with profuse purging which is
not accompanied by any colic or straining—the ‘painless passage of
pints of pale fluid.’ This immediately empties the bowel of all faecal
matter and thereafter the stool consists of slightly opalescent liquid
with small white flakes in it—the so-called ‘rice-water stool’ of cholera.
The onset of diarrhoea is soon followed by vomiting in which liquid
gushes quite uncontrolled from the mouth. The vomit and the stools
arc of similar composition and, as they are highly infectious, they are a
menace to careless and unwary attendants on the case.
The loss of so much body fluid rapidly produces dehydration with
hollow cheeks and sunken eyes; the whole body shrinks and the skin
becomes clammy and inelastic; thirst is extreme and the patient, though
mentally clear, is anxious and restless; the secretion of urine is markedly
diminished or ceases; severe and painful muscular cramps of the
extremities and the abdomen soon occur and the patient’s condition
resembles medical shock. Death may intervene at this stage or the
vomiting and purging may gradually disappear, and be followed by
complete recovery in a matter of a few days. Unfortunately an attack of
cholera provides only a short term protection against another attack.
Previously about 75% of cases in the explosive epidemics died but
with modern treatment promptly and properly applied, the mortality is
very low.

Treatment
The immediate need is to replace the fluid and the salts lost by the
patient before admission and then to maintain his body’s fluids and salts
in balance by carefully measuring and replacing intravenously all that
is lost as the case continues. This requires clinical skill. In addition
tetracycline, one gramme for adults, half that dose for children, should be
given daily in single or divided doses for five days. (The duration
appears to be more important than the dose for preventing the carrier
state.)
As soon as an outbreak starts a fully trained team with its special
cholera cots and its intravenous equipment should be mobilised.

Control of spread of cholera is to be obtained by:—
[a) early detection and isolation of cases and suspects;
(&) immediate disinfection of all the patients’ discharges and their
protection from flies.

7

(c) family and other close contacts should be given tetracycline,
one gramme daily (vide supra) for five days.
(d) ensuring safe water (superchlorination etc.), uninfected food
(strict sanitation of markets, eating houses, dairies etc.);
(c) control of flies (particularly near the hospital, the latrines, the
kitchens and all the eating places);
(/) mass inoculation (cholera vaccine gives a good degree of
protection for about 3 months—and its use greatly restricts
an outbreak);
(g) educate the people in hygienic methods, and enforce them by
temporary regulations where necessary;
(h) isolation of travellers from cholera-infected areas and their
treatment with tetracycline would greatly reduce the risk of
introducing the disease into a new area;
(i) the occurrence of cases must be notified immediately to the
local health authorities and they must warn the World Health
Organization.
THE ENTERIC FEVERS
The group of ‘Enteric Fevers’ consists of typhoid -fever and the
paratyphoid fevers A, B and C.

Typhoid Fever
Typhoid fever is a communicable disease associated with continuous
fever, involvement of lymphoid tissue, enlargement of the spleen, a
rash of rose-coloured spots on the trunk and diarrhoea or constipation
either of which is accompanied by abdominal distension and tenderness.
The fever is associated with the presence of the causal organism in the
blood and with a toxaemia which may be severe. It affects only man and
it is his habits which keep it going.
Typhoid is less common in children under 5 years of age.
Distribution: Typhoid fever is world wide; paratyphoid A is more
common in the East and paratyphoid B in Europe. Paratyphoid C cases
are few but may occur in the northern part of South America (e.g.
Guyana).
This group of diseases is common where standards of personal and
public hygiene are low and rare where they are high. Its incidence thus
forms a useful indicator of the prevailing standard of sanitation.

Causal Organism: Salmonella typhi (the typhoid bacillus): and
Salmonella paratyphi A, B and C in the case of the paratyphoids. The
bacilli are present in the blood during the first two weeks of the illness
and in the faeces and urine after the second week. It is a parasite of man
only.
During the incubation period the S.typhi invade and multiply in
the lymphatic tissue of the small bowel and the neighbouring lymph
8

glands. They then invade the blood stream and localise in the spleen,
bone marrow and gall bladder. The bacilli arc also present in the faeces
and urine generally from the second week, during convalescence and for
a variable period thereafter.
Outside the body the bacillus rarely survives in water for 7 days
and it often dies within 2 days: in sewage it may live for 12 days and in
a septic tank for 14 days; in ice cream for as long as 1 month and on
butter for up to 2 months. It multiplies in fresh milk but is quickly
destroyed if the milk becomes acid (vide WHO Tech. Report Series
No. 288, ‘Enteric Infections’ 1964).
Source of Infection is man, i.e. a frank case of typhoid or a carrier.

Carriers play an important part in the spread of the disease depending
on their standards of personal hygiene and whether they have anything
to do with the handling or preparation of food. About 50% of typhoid
cases continue to excrete the S.typhi in their faeces for about 3 weeks
and about 10% for 3 months after recovery (i.e. convalescent carriers).
Some 2% to 5% become permanent carriers.
Routes of Transmission: Infection results from swallowing food or
liquid that has been contaminated by faeces or urine, or through using
contaminated water to wash raw vegetables, milk containers etc. Soiled
hands are a common source of infection—they may infect food or
utensils. Raw fruits and vegetables are important factors; so also are
milk, milk products, and shellfish. Flies often spread the disease and the
phrase ‘faeces, flies, food’ applies particularly to typhoid.

Incubation Period is usually 10 to 14 days, but may be as short as 7
or as long as 21 days.
Clinical Description: The onset is usually insidious and is associated
with loss of appetite, general weakness, a frontal headache, and some
intestinal upset. The temperature is of the ‘staircase’ type, rising
daily with small remissions till it reaches 103° or 104° by the end of
the first week. The pulse is comparatively slow and bleeding from the
nose is common. The symptoms gradually get worse and a varying
degree of prostration occurs. The abdomen is distended and tender and
there may be diarrhoea or constipation but diarrhoea is general by the
seventh day.
Between the 5th and 7th days a rash of small rose-coloured spots
(2 to 4 mm in diameter) appears on the abdomen and flanks and is
confined to that region. Each spot lasts about 4 days and then disappears
and a new crop of spots appears over the next 10 to 18 days. The spots
fade on pressure, but in severe cases purpura may appear. About the
10th day the Widal reaction becomes positive.
There is a decrease in the number of white blood cells and the spleen
becomes enlarged and palpable.

9

During the second week the temperature remains high with slight
morning remissions. The pulse becomes quicker; the blood pressure
falls; the toxaemia increases and is often associated with a low muttering
delirium.
Commonly some catarrhal bronchitis is present during the first week
and is followed by some congestions of the base of the lungs.
The abdominal distension and discomfort become more marked
and the loose stools (like pea soup in appearance) become darker as a
result of bleeding from the ulceration of Peyer’s patches (i.e. the islands
of lymphoid tissue in the wall of the bowel).
During the third week the patient’s condition may improve; his
symptoms diminish and his temperature fall gradually with daily
remissions. In other cases the abdomen may become more painful and
more distended. It is during this week that the serious complications of
haemorrhage and/or perforation of the ulcers of the bowel may occur.
These cause a sudden collapse. The pulse becomes rapid and thready,
and signs of peritonitis may appear.
It is also about this time that increasingly severe toxaemia may
cause the ‘typhoid state’, i.e., a low muttering delirium or stupor, with
muscular twitching or picking at the bed clothes. The toxaemia may
also cause myocardial degeneration and this is a common cause of death.
During the fourth week favourable cases become convalescent. In
other cases lobar pneumonia or thromophlebitis may occur as complica
tions.
In some 10% of cases relapses occur about 10 days after the end of
the primary' attack. These relapses resemble the initial attack but they
are usually milder in degree and shorter in duration. Occasionally there
is more than one relapse.
Recovery confers a lasting immunity.
Treatment: The specific treatment is the administration of chloram
phenicol by mouth (by injection if the patient is vomiting) and the dose
is 3 grammes a day in divided doses for 7 days, followed by 2 grammes a
day for another 7 days. The temperature generally returns to normal
in 48 to 72 hours and recovery' follows. If chloramphenicol fails it is
well worth trying ampicillin (Penbritin).

Prevention: Safe water supplies—chlorination for the community,
boiling for the individual or family.
Sanitary disposal of human excreta.
Proper sanitary control of food supplies—e.g. pasteurisation (or
boiling) of milk, whether it is used for direct consumption or for making
butter, cheese, ice cream etc. Correct storage and marketing of food
stuffs. Sanitary control of the preparation of food.

10

Control of flies. (Vide Ross Institute Bulletin No. 5.)
Immunisation (T.A.B.) of people going to areas where typhoid is
endemic. T.A.B. (acetone killed) gives 88% protection: phcnol-hcatkilled gives 65% protection. Those still at risk should have a booster at
the end of 2 years. Immunisation against typhoid alone is also possible
but the protection afforded by T.A.B. against paratyphoid is probably
worth while.
The medical authorities will search for typhoid carriers and deal
with them.
Health education on the value of good personal hygiene is usually
required.
Control of an Outbreak
Isolate the case in a fly-proof room. Strict current disinfection.
Immunise contacts and the local community with T.A.B. Chlorinate the
water supplies. Families should boil their drinking water. Careful
personal hygiene—e.g. washing hands after going to the latrine and
before eating. Check all milk supplies. Avoid uncooked food that cannot
be properly washed.
BACILLARY DYSENTERY
If particular bacilli of the Shigella group gain access to the intestinal
tract through food contaminated with them and survive the acidity’ of
the stomach and the digestive fluids of the intestine to reach eventually
the large intestine, they can there propagate with extreme rapidity, in
some instances almost replacing the normal bacterial flora. In the
process of their existence in the bowel they liberate toxic products
which are absorbed into the general system giving rise to the early symptoms
of dysentery. Coincidentally the dysentery bacilli invade the bowel wall
setting up inflammation and ulceration; with this there is an excessive
production of mucus and even bleeding into the contents of the bowel
and the typical symptoms ensue, including frequent evacuations, griping
pain and straining.

The Illness
The severity of the illness which follows depends largely on the
virulence of the strain of the infecting dysentery bacillus. A typical
acute attack lasts about three weeks with fever, severe diarrhoea (twenty
or more stools a day), acute griping pain and persistent straining to
empty the bowel, and stools which contain little other than bloody mucoid
discharge. Recovery usually ensues but some cases relapse into chronic
intractable dysentery.
Fulminating or severe attacks with vomiting, severe headache
and collapse occur in times of epidemics often associated with prisoner
of war or concentration camps or ill-nourished communities ; with
such cases fatalities are common. A natural immunity in individuals or
races does not exist.

11

Chronic bacillary dysentery is a chronic diarrhcra with occasional
recurrences of acute attacks involving the passage of blood and mucus;
obviously, persistent ill-health is a sequel.
An attack of bacillary dysentery confers a certain degree of immunity,
the duration of which is variable but is not likely to be longer than four
months. However, fresh re-infections with dysentery bacilli in small
doses are apt to occur in tropical countries without causing any obvious
symptoms of illness ; such fresh doses of organisms may support and
maintain any previously acquired immunity.
Although common at all ages amongst indigenous peoples, bacillary
dysentery has its most serious effects on children particularly those
under five years of age and mortality is highest in this age group.
Children are the principal reservoir of infection in tropical com
munities ; bow'el evacuation is indiscriminate in and around dwellings
and as the bacilli of dysentery are present in the stools during and for
many days after an attack, it is obvious that widespread transmission
of the organisms can occur, in particular through transfer to food of
minute amounts of stool containing organisms by unclean hands or by
house flies.
Treatment
Mild cases require little general treatment. In the more severely
ill cases the administration of intravenous fluid is often more important
than the administration of antibiotics.
At the earliest sign of illness—commonly unexpected looseness or
mild diarrhoea associated with some feverishness (often in children
the passage of blood and mucus is the first noticeable sign) a doctor
should be called as correct diagnosis is very important. If a doctor is
not available the patient should be given 2 tablets (1 gramme) of
sulphadimidine every 6 hours for 5 days. This dose is for those 15 or
more years of age (for those 1 to 15 years the dose should be half, and
for those under 1 year, quarter this amount). Alternatively phthalylsulphathiazole* 10 to 20 tablets (5 to 10 grammes) in divided doses daily
for 5 days may be administered. See that the patient’s stools are pro
tected from flies and disinfected as soon as practicable. The antibiotics
streptomycin, choramphenicol and the tetracyclines are satisfactory,
but should be taken only on medical advice. They are specially indicated
where there is reason to suspect that the dysentery bacilli concerned
have developed some resistance to the sulphonamides.
Prevention of bacillary dysentery depends on stopping the Shigella
organisms excreted in the faeces of the patient reaching the mouth of
another person. The methods of doing that are discussed in the section
on transmission and control. Flies generally play an important part in
the dissemination of this disease.
•Phthalylsulphathiazole is the official name of the substance, but it is also obtainable under the
proprietary names of Thalazole, Sulphathalidine, Thalistatyl, etc., as tablets or as liquid suspensions.
Succinylsulphathiazole may be purchased under the proprietary names of Sulfasuxidine, Colistatin,
etc., as tablets or suspensions.

12

AMCEBIC DYSENTERY or AMCEBIASIS

Amoebic dysentery is caused by the swallowing of food or water
which has become contaminated with the living cysts of Entamaba
histolytica. Young adult forms of this amceba are liberated from the
cysts into the contents of the bowel ; they are in fact, minute parasitic
animals which are considerably larger than bacteria; some form colonies
within the tissues of the body; to achieve this, each can penetrate the
lining membrane of the large intestine, propagate there by repeated
sub-division and live on the surrounding tissue of the gut; the colony
so created increases in numbers and burrows even deeper. A multi
plicity of such colonies means multiple minute ulcerations of the bowel
lining giving rise to symptoms not unlike those of bacillary dysentery.
Not content with invasion of the intestine itself, amoebae may
find their way into the veins of the intestine and be conveyed by the
blood stream to the liver, where further colonisation occurs causing
inflammation of the liver and subsequently an amoebic abscess.

Fig. 2

LARGE

THE
INTESTINE

The density of the dots
is an indication of the
parts of the large intestine
most commonly affected
by amcebic dysentery, i.e.,
the beginning and the
end.

In both bacillary and amcebic dysentery the patient suffers from
diarrhoea with the passage of some blood and mucus in the stools, but
the former disease is generally acute in its onset, is associated with fever,
painful straining to empty the bowel, and the passage of numerous,
small, odourless stools sometimes consisting of little else than bright
red blood and mucus (resembling red currant jelly). Amcebic dysentery,
on the other hand may be insidious in its onset and is not associated
with fever. The patient passes few stools daily but they are large,
offensive and smelling of decomposing blood.
Treatment: Whereas an attack of bacillary dysentery may be cured by
the administration of a sulpha drug or an antibiotic an infection with
Entamaba histolytica demands skilled medical attention. It is, therefore,
important that the correct diagnosis be made as early as possible, so
13

Fig. 3

AMOEBIASIS — ITS

14

POTENTIALITIES

anyone suffering from an attack of diarrhoea lasting more than 24 hours
should consult a doctor. Modern treatment, properly applied, has
proved very successful, so relapses are uncommon and the incidence of
liver complications has been very greatly reduced. A large number of
people in developing countries, however, never get any treatment at all
and among them the disease takes a heavy toll.
Emetine is still the most effective drug in the treatment of acute
amoebic dysentery, but toxicity limits its use. An acceptable regimen
would be 60 mgs. daily by intramuscular injection for 4 days, followed
by diloxanide furoate (Furamide or Entamide) 0.5G thrice daily for
10 days, or metronidazole (Flagyl) 2 tablets (400 mgs.) thrice daily for
10 days. For amoebic liver abscess either a continuation of Emetine
and chloroquine or metronidazole (Flagyl) alone is currently advocated.
There is no doubt that the degree of severity of illness after
infection varies very considerably in different persons. Outwardly
healthy individuals may be cyst passers and if some other illness occurs
such as malaria, actual amcebic dysentery may flare up. A single massive
dose of cysts in food would almost certainly give rise to acute illness
but more often it is repeated doses of small numbers of cysts from, for
example, an infected water supply which ultimately break down the
natural resistance of a healthy person to produce dysenteric symptoms,
mild, acute or severe. An amcebic infection treated and eliminated
docs not confer any degree of immunity against re-infection later.
At present no prophylactic inoculation is of any avail for protection
against infection with Entamaba histolytica, nor is it customary to take a
drug for preventive purposes. Nevertheless under limited periods of
exposure to infection the taking daily of Furamide, di-iodoquin or
Embequin, etc., by an individual may protect against amcebiasis; a
dosage for the adult would be (di-iodoquin) one tablet (0.3 grammes)
after each of three meals per day.
The possible results of the ingestion of amcebic cysts are illustrated
in Fig. 3: they are influenced by the size and frequency of dosage of
cysts, by the varying susceptibilities of different persons and by the
adequacy of treatment.
RISK OF INFECTION

Bacillary dysentery is present in most countries of the world
but the risk of infection is perhaps greatest where and at the time
of year at which houseflies are plentiful. Human infection with
Entamaba histolytica is also widely disseminated in both tropical and
temperate climates. In bacillary dysentery, infection originates from
the person who is ill or recovering from an attack but in amcebiasis it
comes from an individual who has become a more or less permanent
cyst passer after contracting the disease ; the number of these in any one
community will bear a relationship to local standards of personal and
food hygiene; to the purity of water supplies; and the prevalence of flies.

15

The highly susceptible newcomer to communities in warm
countries is faced with the problem of taking every possible precaution
to ensure that fluids and solid food taken by mouth are uncontaminated
by minute quantities of human excrement—in practice not so easy to
achieve in the home and the hotel without constant watchfulness.
The size of the dose of the infecting germs and the frequency are im
portant in that partially effective precautionary measures may lessen
the dose to a degree that the infection fails to develop and illness does
not result.

If the newcomer develops an illness suggestive of dysentery he
should obtain medical attention ; the doctor may be able to make a
diagnosis on clinical examination as to which form of dysentery his
patient has developed; he can only be certain by a laboratory examination
of the stools, in itself a skilled procedure. In the absence of a doctor
the patient can treat himself on the assumption that it is bacillary
dysentery’ according to the regime on page 12. If the symptoms fail to
respond to treatment within a few days it is quite likely that he may
have an amoebic infection. Double infections can occur also. Under
these circumstances the services of a doctor are imperative if chronic
illness is to be avoided.

16

TRANSMISSION AND CONTROL OF INFLAMMATORY
INTESTINAL DISEASES

All the various organisms which can cause these diseases enter
the body by the mouth, reside, propagate and colonise principally in
the large intestine and leave the body via its waste products or excrement.
Man is the only, or the chief victim of these maladies and it is his
own insanitary habits that are responsible for their continuation and
spread.
The methods of transmission of any intestinal organisms from
person to person are readily seen in Fig. 4.

Water
In many countries it is common practice for children in particular
and adults to empty the bowel on the ground; rain can wash the excre
ment into water courses which may reach the source of supply of water
to the community; although large numbers of bacilli and amcebic
cysts die, some may live a long time in water of stream, river or pond.
Deep well water is usually uncontaminated if the entrance is protected
from seepage and if there are no pit latrines in close proximity.
In the absence of purification processes well water is the safest
for communal use. (See Ross Institute Bulletin No. 10.)
The simplest domestic method of purification is boiling.
Domestic filters are reliable only if they are carefully looked after by
intelligent people. In industry, mines and plantations, water which has
passed through a purification process should be laid on by pipe line to
individual or groups of houses. Filtration followed by chlorination
eliminates bacilli and amoebic cysts but chlorination alone without
filtration may not kill all cysts.
Food
The contamination of food can occur in several ways:
(i) Human excrement is commonly used in some countries to fertilise
the soil of garden crops, particularly those for marketing in bazaars,
etc. The danger lies in the use of fresh excreta ; it could be obviated by
some method of ripening, e.g., composting of refuse with excreta or by
the addition of small quantities of ammonium sulphate which has a
sterilising action and is itself a useful fertiliser. The problem is a
difficult one but not insoluble on estates or market gardens which could
be controlled by enlightened owners or by the local health authority.
(ii) Otherwise clean vegetables of the salad variety or fresh fruit which
are normally eaten in the raw state may be contaminated by washing in
polluted water during preparation for the table ; a safe water should
obviously be used for this purpose.

17

Fig. 4

HOW

THE

PASS

GERMS

FROM

THE

OF

ONE

PERSON

BOWEL

TO

EXCRETA

from
PATIENT or GERM CARRIER

MOUTHS
of

PEOPLE

18

DISEASES

ANOTHER

The individual may take the following precautions when he con
siders his food to be suspect whether it be in a public or private eating
place :—
(a) Select only dishes which have been adequately cooked just
before consumption.
(/>) Do not take any uncooked vegetable particularly of the green
salad type, or fresh fruit without intact skins unless you know
they come from a safe source. Intact fruit should be peeled at
the time of consumption.
(c) Sterilise green salad leaves by immersion for 15 minutes in
undiluted vinegar, which should be the equivalent of a 5 per
cent, solution of acetic acid. (The lettuce should be eaten
soon after, as this treatment impairs its quality.) Other
chemicals, e.g. solutions of chlorine or permanganate of potash
are of very doubtful value.
(iii) Food handlers. A person who has had dysentery recently or
amcebiasis at any time is a potential menace if he or she is involved in
the preparation or handling of food; included are the housewife,
children’s nurse, the servant, cook or waiter and the employee in the
catering business or public eating place, hotel or restaurant. Skilled
laboratory investigation is necessary to determine whether a person is a
carrier of pathogenic intestinal organisms ; from a practical point of view,
this may be possible in individual instances but is very difficult and al
most impossible to apply effectively in public eating places. It is conconceivable that in some countries an enlightened public through its
government might insist that catering establishments should be open to
inspection by health officers to ensure that the ablution facilities for the
employees and the methods of preparation of food will diminish to a
minimum the risk of contamination of the food.
To be precise, the infective food handler is the person who at the
time of evacuation of the bowel, gets the fingers contaminated with small
and frequently invisible amounts of excrement. Dangerous bacilli and
amoebic cysts will not survive on dry fingers for more than ten minutes
or so, unless they happen to get into the moist crevices under or about
the nails. It is obvious therefore that scrubbing of the hands, preferably
with soap in warm water, after the act of evacuation and certainly before
handling food, is an elementary and simple practical preventive measure
easy of application under all circumstances and depending for its success
on the provision of washing facilities at or adjacent to kitchens or food
preparation rooms and the insistence on creating the hand-washing
habit in all concerned. Careful drying of the hands on personal towels
and adequate care of the nails are an essential part of the cleansing
process. In some places and under local circumstances of high prevalence
of dysenteries it may be advisable to go a step further and sterilise the
hands after washing by immersion in an antiseptic solution such as
Dettol or an 0.5% alcoholic or aqueous solution of Chlorhexidine
(Hibitane); or the application to the hands of a cream containing
1% Chlorhexidine.
19

In instances where food-handlers are known to have had dysentery
periodic short courses of drug treatment with phthalylsulphathiazole or
di-iodoquin can be given ; results should be checked if possible by
laboratory examination.
(iv) Houseflies have been incriminated as transmission agents of every
form of communicable intestinal disease, food poisoning, typhoid fever
and bacillary and amoebic dysentery. Indeed so important are they in
many countries that the incidence of bowel disease waxes and wanes with
the increase and decrease in the fly population. The mechanism of
transmission is simply that flies normally and equally feed on human or
animal excreta and human food ; they may, therefore, carry organisms
of disease on their bodies or ingest them and later deposit them in vomit
drops on human food in the food storage room, the kitchen or on the
dining table.
Flies must therefore be dealt with by every available means (vide
Ross Institute Bulletin No. 5), summarised as follows:—
(a) Control of breeding places by incineration, burying, or
composting of animal, human and vegetable filth.
(4) Prevention of access of flies to latrines, dwelling houses,
and in particular, food storage rooms and kitchens.
(c) Protection of food in the house by suitable covers; this
applies particularly to fruit, sugar and milk.
(d) The regular use of insecticides of both the residual (D.D.T.
and benzene hexachloride) and space spray knock down types
(pyrethrum) in the household or catering establishment.
The routine outdoor use of residual insecticides on breeding
grounds, e.g., rubbish dumps, only succeeds in producing
sooner or later a race of flies resistant to insecticide.

Direct Transmission can readily occur in institutions or house
holds where the level of personal hygiene is low, particularly between
children. Clothing, toys and similar objects can be readily contaminated
with excrement which reaches the mouth by way of the object itself or
the fingers. In tropical places where children evacuate the bowel
indiscriminately, amoebic cysts may remain alive on the surface of
permanently damp soil to constitute a risk to other children playing on
it.
Sanitation
It may be a ‘counsel of perfection’ to insist on the importance
of the proper disposal of human excreta (vide Ross Institute Bulletin
No. 8) by whatever means may suit the local circumstances and so help
to ensure that water supplies are not contaminated and that flies do not
readily pick up pathogenic organisms. The higher the degree of
insanitation the higher the incidence of intestinal diseases! The solution
of the problem of the sanitary disposal of human waste matter is
fundamental in the control of these diseases.

D/ S’ 2^’21

0/2^

COMMIT’.'.'
CEEL
47/1,(First'• ->0 ' ' - •••arksxoad

Basically it is a household or family problem: an easily accessible
latrine should be the only place of excreta disposal by men, women and
children. Such a system universally applied in rural areas and villages
of a country’ can only’ be achieved when the people collectively realise
the reason for the radical change in age-old traditional habits, namely
the control of intestinal disease and worm infestations. A change of
this nature could occur over a period of years and would depend largely
on the enlightenment of women and the training of children; the demand
for this household convenience must come from the people themselves.
In urban areas and industrial villages the sanitarian can achieve
results more quickly through the application of bye-laws insisting on
the provision and maintenance of latrines for individual premises.
Experience has shown that communal latrines are actively disliked by
most peoples and their construction should be restricted to such public
places as factories, schools, meeting places, etc.
Latrine systems are described and diagrammatically illustrated
in the Ross Institute Bulletin No. 8, ‘Rural Sanitation in the Tropics’.

22

PUBLICATIONS OF THE ROSS INSTITUTE

The Preservation of Personal Health in Warm Climates.
(A handbook for those going to the tropics for the first time)

Ross Institute Bulletins :—
(1)

Insecticides. (Reprinted) June, 1969.

(2)

Anti-Malarial Drugs. (Revised) February, 1966.

(3)

The James Forrest Lecture. The Interdependence of
Medical Science and Engineering. (Out of Print.)

(4)

Tropical Ulcer. (Revised) May, 1965.

(5)

The Housefly and its Control. (Reprinted) June, 1969.

(6)

Schistosomiasis. (Revised) April, 1970.

(7)

Malaria and its Control. (Re-written) June, 1969.

(8)

Rural Sanitation in the Tropics. (Revised) May, 1968

(9)

The Inflammatory Diseases of the Bowel.
(Revised) August, 1970.

(10)

Small Water Supplies. (Revised) September, 1967.

(11)

Iron Deficiency Anaemia. (Out of Print.)

(12)

Protein Calorie Malnutrition in Children. (Revised) August,
1970.

These publications are reviewed from time to time and new and revised
editions are issued as occasion warrants. They are available at printing
cost plus postage on application to:—

The Secretary,
The Ross Institute,
London School of Hygiene & Tropical Medicine,
Keppel Street, Gower Street,
London, WC1E 7HT.
Tel: 01-636 8636

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