On Marasmus as an Occasional Consequence of Enteric Fever
Authors: T. C. Allbutt
Journal: BMJ (1871)

WE not uncommonly meet in practice with cases of general wasting which do not tend quickly to death, but which, on the other hand, are almost incurable.We can find no organic disease, but the patient loses flesh and turns sallow, until, when stripped, he seems almost a living skeleton.In this state, he may survive many years, unfit for exertion; eating food and getting no good from it; spending his substance upon physicians, and growing thereby no better, but rather the worse.Such cases of wasted, sallow, feeble frames, without any definite disease, must have occurred in the practice of many or most of us.It was not until several of these cases had presented themselves to me as riddles which had to be given up, that I ventured to guess at a solution which may be true, at any rate, for some of them.It so happened that, in more than one instance, on writing the notes of the patient's previous history, the symptoms seemed to date from a precedent attack of enteric fever.Up to the onset of this illness, the patient had enjoyed good health; but, after it had passed by, he re- mained feeble, his convalescence was protracted, and, although perhaps he did regain flesh and strength in some considerable degree, yet in a few months more this new flesh fell again from his bones, and left him wan, wasted, and spiritless.Thus my attention was drawn to the question of the connection between such a marasmus and a precedent attack of enteric fever; and this question once raised, the answer to it does not seem far to seek.I am rather surprised, on turning over the leading treatises on enteric fever, to find that the chance of so severe an abdominal disease permanently affecting nutrition, has not presented itself to the writers; nor do I ever remember to have heard this disease suspected of doing more than temporary mischief.But when wye look at the parts affected by this fever, when we remember how severely it falls upon a large part of the absorbent surface of the intestine, and upon the glands of the mesentery, it would seem likely, a priori, that in some instances absorption might be permanently interfered with.I shall now proceed to read short notes of five cases of this kind which have occurred in my practice since my opinions on the subject were formed, and in which careful and particular inquiry was made from the present point of view.CASE I.-Miss H. R., aged 25, had always enjoyed good health until she had a severe attack of enteric fever about two years ago.Latterly, she was believed to be phthisical, and had consulted many medical men from that point of view.Slie came to me on May 6th, I870.She had lost flesh greatly, so that her bones stood out in almost startling relief; the eyes were sunken, and the complexion sallow.She had no night- sweats, and the temperature, at I1.30 A.M., was only 97.6 deg.Fahr.The tongue was clean, and the appetite was fair.Meat agreed best with her, and mutton chops in particular; fatty substances disordered her stomach, and made her "bilious."She was very liable to flatulence, though the abdomen was rather sunken than prominent, and she was much annoyed by loud rumblings in the bowels.She was unable to give much account of the appearance of the motions, but these and the catamenia were regular.This wasting in spite of the ingestion of fair quantities of food had been conming on for about a year, or pro- bably for a longer time.Her convalescence from the fever, in fact, was delusive.Slowly she seemed to improve for about six months, then she remained at a standstill for a while, and, a few months later, the wasting steadily set in.I examined this patient most minutely; during the time she was under my observation, I saw her at home in bed, and left no organ without investigation.Every part, however, seemed quite normal, so far as I could tell.I tried various remedies, including pancreatised fats, but without success; and she left me for another adviser.