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INTERNAL INTESTINAL FISTULAE CAUSED by AMOEBIASIS a FIRST REPORT MJCHAEL DJ Fer L.R.C.P

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INTERNAL INTESTINAL FISTULAE CAUSED by AMOEBIASIS a FIRST REPORT MJCHAEL DJ Fer L.R.C.P 808 S.A. MEDICAL JOURNAL 30 September 1961 by pressure bandage, and by pressure on 'pressure points' propagandized among our first-aid organizations in South are still taught as first-aid manoeuvres - doubtless as a Africa. relic of the times before antibiotics and control of infec­ Other accepted first-aid procedures that also require tion, when most other methods of control were better than consideration are our methods of splinting. If we are going direct pressure on an open wound with all its risks of to move patients with safety, we should stop paying lip po sible contamination. Direct pressure is easy to apply, er ice only to the dictum ' plint them where they lie', can be taught quickly and, while it is effective, it permit and start pressing for the more extended use of the a limb to survive transport and delay. A few turns of a Thomas' plint among first-aiders for fractures of the firm, crepe bandage applied over a pad can control any lower limb. This splint is, to date, the best available and haemorrhage without subjecting the patient to the agonies is incomparably superior to any other simple means of of a tourniquet - with or without a stone in the hand­ fixation; and the long Liston splint, which is usually used kerchief and a turnbuckle. Any haemorrhage that is con­ (Liston, after all, died in 1847), should perhaps be relegated trollable by tourniquet can be better controlled by a firm, to the surgical junkyard and museum to join the other crepe bandage that is applied directly over the wound implements that have served their purpose and are no and is a far safer form of treatment. longer recommended or in use. While it may be unthinkable at the moment to make any And finally, though this is put forward rather diffi­ drastic alteration in the first-aid manuals' " (which, spon­ dently, has the time not arrived for us to consider whether sored by such world-wide organizations as the Red Cross it would not be possible to train ambulance men in country and the St. John Ambulance Association, have stood the districts to set up a simple intravenous drip with plasma? test of time and have enabled these bodies to render splen­ It can be categorically stated that no seriously injured, did services), it is not right that our mental processes but previously healthy, adult _can derive anything but should become ossified and immobilized by admiration for benefit from 500 m!. of plasma administered intravenously, old-standing institutions. Improvements can be made and drop by drop. The technique is safe and simple to learn. should be suggested. Undoubtedly another such improve­ The U.S. Army has trained its ambulance-corps men to ment is in the teaching of artificial respiration. Schafer's set up blood transfusion in the field. Perhaps we, too, method, Eve's method and others should give way to in­ should press for a little more positive thought and ac~ion. tensive teaching of the mouth-to-mouth or the expired­ air-insufflation method which has recently won the ap­ 1. Tbe autborized manual of St. Jobn Ambulance Association. Si. Andrew's proval of the American Red Cross Association. 'Safar,3 Ambulance Association, and the Britisb Red Cross Societ}' (1960): Firs,- Aid, 12th impression. .. and similar tubes are readily available in this country for 2. Irvine, L. G .. ed. Matbews, R. A. (958): Manual of FlTst-Ard. Cape Town: South African Red Cross Societ}'. use in this emergency, and this method must be properly 3. Safar, P. and MacMahon. M. (1958): J. Amer. Med. Assoc., 166. 1459. CARDIAC TECHNOLOGISTS Elsewhere in this issue are published the proceedings of the technologist. Cardiac catheterization, angiocardiography, first graduation ceremony, which was held recently at and open-heart surgery could not take place without the Groote Schuur Hospital, Cape Town, to grant diplomas attention and scientific training and help that the cardiac to successful candidates for the Diploma of Associate technicians now give to the cardiologist. Membership of the Society of Cardiological Technolo­ Advance courses are now to be held for the Fellowship gists of South Africa. This was indeed a happy occasion of the Society of Cardiological Technologists which will and a natural result of the rapid development of cardio­ further enhance the efficiency and training of technicians. logical practice in this country. More and more demand will arise for technicians in every Full credit must go to the Southern African Cardiac branch of medicine, because clinical medicine cannot pro­ Society and to the other members of the Cardiplogical gress without laboratory help in the very necessary special Technologists Society of South Africa for the success of investigations. this project. There is no doubt that in modem cardiology a great We congratulate all those concerned in this worth-while part of the success of the investigations is owed to the project and wish them success for the future. INTERNAL INTESTINAL FISTULAE CAUSED BY AMOEBIASIS A FIRST REPORT MJCHAEL DJ fER L.R.C.P. & S. (EDIN.), L.R.F.P.S. (GLASG.), F.R.C.S. (Em .), Surgeon .. and ELUOTI BADER, M.B., B.CH. (RAND), F.R.C.S. (ENG.), Assistant Surgeon Baragwanath Hospital and the University of the Witwatersrand, Johannesburg Though stricture of the colon has frequently been reported A recent experience at Baragwanath Hospital has and is well known as a late complication of amoebiasis, prompted us to review the problem, and as a result we there is no report in the literature of internal fistula wish to present the following 4 cases of actual or impend­ caused by amoebiasi . ing amoebic internal fistula, in the form of a preliminary 30 ptember 1961 S.A. TYDSKRIF VIR GENEESKUNDE 809 report to further investigation which is proceeding. Speculation about the part played by the abdominal injury in this rare complication of amoebia of intere t, but no CASE 1 conclusive deduction can be made. 2., an adult African male, aged 49, wa admitted lO Baragwa­ nath Hospital on 23 February 1957 with a hi tory of everal CASE 2 weeks of abdominal pain followed by severe diarrhoea and J.K., an African male, aged 40, wa admitted to Barag\ anath extreme weakness. He stated that he su tained an abdominal Ho pital on 20 March 1959 with a ID-week hi tory of abdomi­ injury in December 1956, and dated the abdominal pain from nal pain. continuous in nature and unrelated to food. There Ihat lime. had been no vomiting or diarrhoea, but on 0 casion he had Examination revealed a grossly dehydrated and emaciated passed tarry tool. patient wilh a generalized peritoniti . An X-ray of the abdo­ At a small country hospital he wa een by a doctor who men howed ga under the diaphragm. The clinical diagno is noted a mass in the left hypochondrium. A laparotomy wa of amoebic perforation of the colon was not substantiated, carried out and an inoperable tumour wa diagno ed. 0 in spite of the fact that 9 stool examinations were made biopsy w performed and the abdomen wa clo ed. He was during the next few days. then tran ferred lO this hospital for further treatment. Meanwhile, on conservative therapy for generalized peri­ Examination on admission revealed a wa ted Banlu male IOniti, Ihe patient made a slow recovery. A barium enema, with a mobile ma s in tbe left hypochondrium, about 3 inches performed after the acute episode had subsided, showed a in diameter. Blood, stool and radiological investigation, in­ colitis with enterocolic fistula (Fig. 1). cluding X-rays of chest and abdomen, pneumoperitoneum and These findings in an African prompted a diagno is of ulcera­ intravenous pyelogram, proved unhelpful. tive colitis. Symptoms persisted with deterioration of the However, a barium enema showed an area of extreme patient's condition, and a terminal ileostomy was carried out narrowing of the left half of tbe transverse colon. The whole on 25 April a a desperate measure. The poor condition of transverse colon was displaced downward in a U-shaped the patient and the presence of a plastic peritonitis precluded curve (Fig. 2), and air-contrast studies howed a normal an extensive laparotomy. mucosal pattern in spite of the presence of an undilatable Po lOperatively the patient's condition improved slightly, but tricture. after a further deterioration he died 10 days later. Autopsy ,howed multiple perforations of the colon with pericolic abscess A barium meal showed a normal gastric mucosal pattern, formation, multiple adhesions, and enterocolic fi tulae. On but along the greater curvature there was a long curved inden­ microscopic examination Entamoeba histolyrica were found in tation suggestive of a mass distorting the tomach. Lateral sections taken from the colon. and oblique films showed the tomach lO be displaced anteriorly. Commenr The conclusion drawn was that a tumour mass, either in Thi i a case of amoebic perforation of the colon with sub­ the lesser sac or in the gastrocolic omentum, was present. The sequent enterocolic fistula formation. The fact that amoebiasis apparently normal colonic muco al pattern a sociated with was not considered as an aeuological factor in fistula forma­ stricture of the colon remained a puzzling feature. tion led lO misdiagnosis and the ultimate death of the patient. Following intestinal sterilization, operation was undertaken It is of interest that, in a hospital where amoebiasis is on 27 May, and a mass involving the greater curvature of the fairly common, 9 separate stool examinations failed to reveal stomach, the greater omentum and the tran verse colon was the pathogen. found. A resection, including both greater curvature and Fig.
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