By Dr. E. Cachemaille Boxer, Hastings, H.B.
Read at meeting of Hawkes Bay Division B.M.A. and published in NZMJ Sept 1913;12(47):504.
Gordon F., age 6, was first brought under my notice in October, 1912, his father coming in from the country saying that his boy had sharp diarrhoea, with almost pure blood in the stools. I prescribed an astringent and told them to let me know further progress. This was on Friday, the condition having started on Thursday; the following Sunday I went out to see him as there was no improvement.
I found the boy looking ill and drawn, with a typical abdominal facies, no temperature, pulse 80, some tympanites, no down-bearing, very slight abdominal tenderness on palpation, but with no pain. On examination a sausage-shaped tumour was easily felt in the left iliac fossa above and to the inner side of the sigmoid flexure, and quite distinct thereform.
My partner saw the case with me at the same time, and we agreed as to the diagnosis of intussusception. The patient's stools were thin and watery, painless, but with copious bright blood. We removed him at once to a private hospital, as he was obviously very ill. A third opinion was sought that night, and it agreed with our own.
Late that night, i.e., about 72 hours after the onset of the haemorrhage, I operated. On opening the peritoneum no morbid changes were at first visible. There was no sign whatever of the tumour that had been felt per rectum half all hour previously. Nonplussed, each of us followed out the whole course of the small intestine, and could not even see evidence of recently reduced intussusception. The large intestine looked inflamed and oedematous, and some deep glands, suspiciously tubercular looking, were felt in the mesentery. As the appendix looked catarrhal, I removed it, but found nothing to account for the haemorrhage:
The wound healed by first intention. Up to this point there had been no temperature, but about 5 days after operation the patient began to run a hectic temperature, which lasted more than a fortnight. During this time the motions, on an average 6-8 in a day, were profuse, yellow and grey in colour, and always streaked with blood, while at times they were nearly entirely blood. We now calculated it must have been a case of acute colitis, and the tumour a myth. Under persistent douching and saline injections he recovered slowly and in three weeks time was able to be moved home.
A week later, his mother said that the day before he had had a very severe attack of abdominal pain, and that his motion, hitherto not offensive, had suddenly become over-poweringly foul, so much so that they could scarcely go near him. Without attaching any particular importance to the fact she added that, "late last night he passed what looked like a piece of a finger of an old glove, black, like a piece of decayed flesh, about 2 inches long, and all covered with little veins. The smell was too awful to keep it to show you, so we buried it at once."
There seems little doubt that this was the intussusception originally felt; for from this stage the boy made a rapid recovery.
The chief points of interest are:
1. The complete absence of one of the cardinal symptoms, viz., pain.
2.The complete absence of the tumour at the laparotomy.
3. The complete absence of any sign of obstruction at any time of the illness.
4. The final passage of the complete intussusception five weeks after its onset.