DIAGNOSING AMŒBIASIS

489 ment of the liver downwards or upwards and an area of is explored first in each case, before the incision is continued into the thorax. But pain or tenderness in the right lobe. These last two signs he does not appear to do this. Apparently he explores rapidly disappear after the first few injections of emetine. In a military hospital I saw lately two unsuspected the abdomen first in a " primary gastric growth... cases of chronic amoebiasis. when serious doubt exists about the operability." I maintain that it is often not possible to decide before CASE 1.-A. regular soldier of 39 years complained of loss operation whether a tumour is primarily gastric, or from of weight, loss of appetite, shortness of breath, dry cough, the abdominal or thoracic oesophagus. Also, I feel that and retrosternal pains. He looked ill, and the first clinical it is seldom, if ever, possible to be sure that any tumour impression suggested growth of the lung. However, all chest in this area is operable, as regards the extent of spread investigations. were negative, the X-ray film showing increased of the disease or the fitness of the patient for operation, vascularity of the right base. The liver was found to be very without exploring the abdomen.3 I strongly disagree tender on pressure in the anterior axillary line. Sigmoidoscopy with Mr. Allison’s suggestion of exploring the thorax first and stool examinations were strongly suggestive of amoebiasis, in dealing with primary growths in the lower oesophagus, but not conclusive. There was dramatic response to an antior usually making a complete exposure, because of the amoebic course. There was no history of " blood and mucus." possibility of metastases in the abdominal lymphatic CASE 2.-A soldier of 27 complained of loss of weight, Should " radical treatment " (presumably glands. fatigue, indigestion, and obscure abdominal pain. A few excision) be impossible, the only other methods justifying bouts of " Egyptian tummy " (short attacks of profuse a ".complete exposure " are direct irradiation (which he were admitted. arose when localised diarrhoea) Suspicion does not mention) and palliative resection. But even if tenderness in the ascending colon was found, together with the former is contemplated the abdomen should be tenderness of the right lobe of the liver. Typical amoebic explored first, as discussed above. The only. other ulcers were demonstrated by sigmoidoseopy. The response palliative operation worth consideration is gastrostomv. to emetine was dramatic. Although this is a very worth-while procedure, it hardly It should be borne in mind that the infection is very calls for a complete exposure." in its onset ; and the organism is not easily insidious Mount Vernon Hospital, Northdwood, ALAN SHORTER. identified in the stool. It sometimes can be seen after Middlesex. 5-6 a double dose of salts, or by a penicillin enema ; SCHISTOSOMIASIS specimens must be then examined during one day. But there is nothing more to go on than suspicion. SiR,-Among the few post-mortem examinations that sometimes The latest edition of the War Office memorandum 2 rightly have been made on persons dying whilst undergoing recommends the therapeutic use of emetine in these cases. the " lightning cure "’ for schistosomiasis no record Valuable time is often wasted. by denying the patient has appeared of the presence of dying worms in the initial course of succinyl sulphathiazole, with conpulmonary system or other sites where the dislodged an penicillin. The best results are obtained by parasites were found in sheep similarly treated with currentten giving injections of emetine gr. 1 daily after five days’ massive doses of antimonium potassium tartrate. preparation with succinyl sulphathiazole ; during the It would be interesting to know whether this new form emetine treatment penicillin 300,000 units is given of treatment has been favoured in the Far East, where, however, sodium preparations of the drug might tend to 8-hourly. This course is followed by eight doses of emetine bismuth iodide gr. 3 at night ; concurrently influence unduly an’already impaired liver. Such a liver ’Diodoquin’ may be given, and vitamin-B compound would probably be less capable of dealing with the tablets and a high-protein diet are recommended. The successful destruction of a large number of these ten emetine injections are essential only in cases of liver elongated parasites of the blood-vessels. involvement; but this .is nearly always present in the F. G. CAWSTON. chronic form of the disease. A. ERDEI. Cambridge Hospital, Aldershot. DIAGNOSING AMŒBIASIS SiR,-Dr. Robertson’s case of acute amcebiasis com- URETHANE AND STILBAMIDINE IN MULTIPLE plicating cholecystectomy, reported in your issue of MYELOMA Sept. 6, is another warning that the infection must be SiR,-I read with interest Dr. Alwall’s article and seriously considered in all cases of colitis, and even of obscure abdominal or hepatic symptoms. your annotation in the issue of Sept. 13. The annotation refers to the " dissociated trigeminal anaesthesia " Our knowledge of amoebiasis has advanced so much during the last few years that the textbooks have simply that may occur as a delayed sequel to treatment with stilbamidine. May I underline this reference ? fallen out of step. The practitioner who still expects to We found that this sequel, which we looked on at find " blood and mucus " in the stools, or at least the history of such occurrence, is likely to miss quite a few first as rare and interesting rather than serious, occurred in more than half the cases with which we maintained cases of chronic infection. It is still not sufficiently well known that amcebiasis may be present without any contact, and, though in the majority the symptoms were history of dysentery ; however in most cases there will be slight and needed a leading question to elicit them, they a history of irregularity of the bowels and, perhaps bouts might be severe and dominate the patient’s life for months or even years. One of our patients was in a of profuse diarrhoea with loose motions at other times, suicidal mood as a result of tingling, formication, and and obscure abdominal pain ; and some patients will volunteer the observation that they seem to be using more hypersesthesia of the affected area for several months. The neuropathy usually appeared 3-4 months after the toilet paper than they ever did before. termination of treatment. On account of this sequel It is also not sufficiently known that acute or chronic and a suspicion regarding the rare occurrence of graver amcebiasis can exist in people who have never been in the tropics. Edson and othersdescribed 39 cases in sequelae, I have for some time recommended that this an American camp in Northern Ireland among fresh drug should be reserved for proven antimony-resistant troops who had never been outside the U.S.A. Of these cases. More recently, Lieut.-Colonel W. H. Hargreaves, 39, 12 had never even been in the southern States where R.A.1B’I.C., has found that trigeminal neuropathy followed in almost every case in which he used the drug.3 We amoebiasis is known to occur. In one division 20 % of the food-handlers were found to be carriers ; and such did not observe it in any case where we used the far less carriers are likely to appear in this country among the effective (in kala-azar) pentamidine (4-4’-diamidinosoldiers returning from the Far East. diphenoxy-pentane). In Edson’s series of 39, only7 had history of " blood and It seems possible that stilbamidine is coming into more mucus " ; the others complained merely of irregularity general use in this country, so I feel that a warning of the bowels, of obscure abdominal pains and distenshould be issued here. Colonel Hargreaves has, I know, sion, and of growing fatigue. They could fall asleep any already called attention to the danger of this drug in the United States. time during the day, but sleep was not refreshing. Apart L. EVERARD NAPIER. from the signs of colitis this fatigue is one of the most constant signs of amcebiasis, together with some enlarge-

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1. Edson, J. N., Ingegno, A. P., D’Albora, J. B. 1945, 23, 961.

Ann. intern. Med.

2. Medical Diseases in Tropical and Sub-Tropical Areas. Stationery Office. 1946. 3. Milit. Surg. 1947, 100, 212.

H.M.