341INFANTILE MARASMUS.

the patient was sneezing. The woundswere healed up after about seven weeks.

B., ætat. 21, of fair complexion, receivedin a duel a cut across the face, by whichpart of the tip of the nose, the alas, anda portion of the septum, were separated ; ! Ithe piece was immediately reapplied, andkept in its place for a few minutes with the Ifingers, and then by means of a uniting i

bandage. The skin of the patient was soirritable, that the sticking-plaster caused anerysipelatous inflammation and a papularouption, notwithstanding which, how ever,reunion was found to be complete on thethird day, yet the separated piece was of abluish colour, and it was expected that Illor-’tification would ensue ; the skin became de-tached on the following day and carue away,leaving an unhealthy suppurating surface ;under the repeated application of a balsamicointmetit, and the solution of sublimate, theulceratioti became of a more I)e.iltliy cha-racter, and after a ffw days the wound be-

gan to granulate. The separated piece re-tained its vitality, and cicatrization was

completed on the 10th day.Besides these four, the above journal

contains twelve more cases, all observed by fthe same practitioner, in most of which re-union proved successful.

LONDON MEDICAL SOCIETY.

November 8, 1830.

Mr. CALLAWAY in the Chair.

INFANTILE MARASMUS.

Mr. DENDY this evening read a paper,on the pathology and treatment of infantilemarasmus. !The study of those morbid affections which

occur during the period of infancy is one, isaid Mr. Dendy, replete with interest. The,helpless condition of the patient, the obscu-rity of the symptoms, the sudden exposureof the frame to the influence of externalagents, the abrupt assumption of the dutieswhich belong to the alimentary canal, andextreme susceptibility of the nervous system,are all matters of interest and importance.Among’st the diseases which are arranged

in the infantile nosology, there are few, thecauses, symptoms, seat, and treatment ofwInch have excited so great a diversity ofopinion a-7; th malady which has been de-nominated—macies—atrophia lactantium—febris infantum remittens—hectic fever-tabes mesenterica—marasmus. The causesof this diversity may have been various.

The immediate cause of marasmus is in-efficient nutrition, arising either from a di-minished or suppressed absorption of chyle,or by a deteriorated condition of that fluidwhich renders it, if absorbed, unfit for itsimportant office in the animal economy.For although irritation of the nervous sys-tem may prove fatal of itself, it does so

usually by its immediate effects on thebrain, or the medtilla. If the irritation bemore protracted, the functions of the intes-tinal canal are from this cause deranged.These affections, as well as partial wastingor paralysis, it is not my purpose to treat.A healthy bodv, especially that of the child,is in a state of constant renovation and in-crease. The siipervention of disease inthose organs which perform this importantfunction incapacitates them for their duty ;their function is either altered, or suspended,or destroyed.

Granting some absorbing power to othertubes, the grand medium of nutrition is thelacteal apparatus of the intestines. What-ever, therefore, deranges the function or

disorganises the structure of the mucousmembrane of the alimentary tube, may beconsidered the exciting cause of marasmus.The chief of these causes are-retention of £the meconium—dentition—exposure to cold- the recession of eruptions--deficient or ex-cessive supply of alitneixt-deleterious food-worms-the poisons of measles, scarlatina,small-pox- of which diseases intestinalirritation and its consequent diarrhoea are themost frequent sequelae. To this list it maybe expected I should add those cases of

profuse or increased discharges which aremarked usually by wasting, as coryza, leu-corrhora, and perhaps diabetes, but if I ad-mit those it would lead me to digress, as theemaciation attending them is a consequenceof almost every disease in infancy. I wishhere to confine myself to the abdominalsources of marasmus.

I consider then that there are two con-ditions of the mucous membrane of thebowels which induce marasmus-simple ir-ritation and inflammation, or muco-enteritis- often a disease into which by neglect sim-ple irritation may be excited, a fact whichagrees with the opinion of Dr. Goelis, thatthe majority of infantile diseases bear an

inflammatory character. I do not mean toassert that this diseased action invariablycommences irrthe mucous membrane ; manyinstances have, I doubt not, occurred whereidiopathic inflammation of the peritoneumhas been the primary disease, extending inthe end to the mucous surfaces ; althoughwhere we have ulcerations, and even fistu-lous openings at the points where the con-volutions of the intestines lie in contact ; itwill be a difficult task to say in which tunicthe disease first commenced. I believe,

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however, that peritonitis is marked usually establish the remedy-a salutary, or criticalby the adhesive inflammation, and muco- diarrhoea.enteritis by the morbid changes I have Simple -It,ritation,-Ts characterised byalluded to above. I am anxious to esta- those symptoms which have been termedblish, as far as I can, the proper seat and mesenteric and infantile remitting fever.nature of this distressing disease, because It is seldom that the disorder is observed byI think that error regarding this circum- us in its first stage, the treatment of whichstance has been productive of frequent un- is usually confined to the nursery. Thesuccessful practice. The pathologist has child is restless and fretful, the prominentbeen led away from the commencement of symptom being often simply constipation.the lacteal tubes, by a fancied importance To this succeeds a contrary condition of theattaching to the mesenteric glands in the alimentary canal ; the secretion of the mu.function of nutrition, or the tonic or stimu- cous surface is increased, the effort of thelant plan been resorted to when depletory system, in fact, to dislodge a load from themeasures have been indicated. Hence bowels, and we have mucous diarrhoea es-wasting of the body has been described by tablished. This is the stage at which thethe sweeping term tabes mesenterica, be- patient is usually presented to us. Thecause a suppurating’ gland has been some- evacuations are mucous, slimy, or watery,times discovered on examination. Mybooks sometimes of a grass-green mixed withhad led me also into this error, but expe- flakes of mucus, and sometimes streakedrience has often shown me, on the dissection with blood. Small hard buttons of feculentof fatal cases of marasmus, how slight, if matter are often evacuated with the mucus,any, disease existed in the mesenteric and these are attended by a most painfulglands-how extensive were the lesions of tenesmus : in the intervals the abdominalthe mucous and peritoneal coats of the in- pain often ceases entirely, and the child willtestines. then suck freely and even eagerly, and ap.The suppuration of mesenteric glands is pear lively. The heat of skin is not much

generally a secondary disease, extending increased, the pulse is accelerated, rangingfrom other tissues ; or in the scrophulous often above 100, the lips are dry, and thereenlargement, it may be an ineffectual effort is often an aphthous affection of the liningto expel some constitutional taint; or an membrane of the mouth. Gentle pressureincapability of resisting that action which, on the abdomen will rather soothe than irri-in a vigorous system, and within due limits, tate ; and the child will even bear deepis set up to repair or relieve the vis medi- and firm pressure of the hand without cry-catrixnaturas. ing,-the expression of complaint indeed, is

I believe that muco-enteritis may often generally more fretting than crying. Thisexist as a primary affection, yet it may be state will soon become aggravated; theconsidered also as an aggravated form, a diarrhoea and tenesmus will be more con-

consequence of previous irritation ; but as stant-often incessant, and prolapsus anithe removal of that exciting cause will not will take place. The child will becomeeffect the subsidence of an established in- pallid-often of a livid complexion; the

flammatory action, the distribution of the appetite fails ; the pulse becomes less per-causes of marasmus into simple irritation ceptible ; the exacerbations of fever moreand inflammation becomes of the greatest frequent; the emaciation extreme ; and in

practical value, equal in importance to a this condition the child will gradually sink.knowledge of the seat of excitement. In these cases dissection will discover to

Irritation may be termed a disorder of us little morbid change in the abdomen, ex-function-inflammation that of structure. In cept, perhaps, a superabundance of flakythis distinction consists the practical im- mncus, or, in a protracted disorder, a pecu-portance, which if we disregard, we may on liar emptiness of the alimentary tube ; thethe one hand drain the system of its blood colon will be often distended with gas, andto absolute exhaustion with none but a fatal throughout the small intestines numerouseffect ; on the other, we shall neglect those volvuli are often found. Death then usuallymeasures without which the same disap- occurs from a mere deficiency of absorption;pointment will follow. I shall, therefore, the contents of the bowels being hurriedconsider separately, but briefly, these two past the mouths of the lacteals with greatconditions of the mucous surface. If I have rapidity ; of this condition I might citemade myself understood, it will be perceiv- numerous examples.ed that I presume to endow these varied In this disease, however, as in manyexcitements with the power of producing others, there may be a remote sympathythe two diseases indiscriminately, but the with other organs, which we are apt to

action established on the membrane by the overlook ; with the membranes of the brainspecific excitements—measles, scarlatina, especially, in which chronic meningitis andand small-pox-is, similar to themselves, a ventricular effusion-.take place, as it willdisease -for which nature herself wiil often indeed even in cases of extreme irritability,

343

owing to the quality or quantity of milk fromprotracted suckling.

Muco-Enteritis.—In this disease we havesome symptoms in common. It may, how-

ever, be distinguished from irritation bya more oppressed though fuller pulse, bygreater heat of skin, by a physiognomic ex-pressionof suffering, especially about the alænasi and the lips, in the early stage by a feeblethough shrill cry or scream, in the tatterperiod by a dull moaning. There is a parchedcondition of the mouth and lips ; the head istossed to and fro ; the pupils are much con-tracted asin meningitis, or dilated as in effu-sion (febris gastrica, or synochus) ; the legsare drawn up towards the abdomen, the bellyis tumid, and there is pain felt on deep pres-sure. The absence of constipation will dis-tinguish this, I think, from peritonitis, orat least from idiopathic inflammation of theperitoneum commencing in that membrane.The evacuations, in the advanced stage, areof a very peculiar character, a greyish pulpymasstike chewed paper. If the ear is ap-plied to the belly there is a sound of con-s,tant guraling, obeying the motion of the

diaphragm in breathing, differing from theusual sound of peristaltic action. Eventuallythe pain will be more severe on pressure, andmore extensively diffused ; the peritoneumhas partaken of the disease.There is an essential difference in the

type of fever, in the second form, there areseldom if ever remissions, the local excite-ment being constant.On the examination, especially of pro-

tracted cases, the abdominal viscera willoften be found matted together, so that itis difficult to distinguish them from each

other, ulcerated or fistulous openings willbe found perforating their coats. Both inthe cavity of the abdomen, if that be not ’,obliterated, and in the intestinal tube, pulpyor slimy, or purulent matter will be found.Livid patches are sometimes observed bothon the surfaces of the intestines and theskin. The mesenteric glands will some-times be found enlarged in this stage of thedisease, and in a state of suppuration. Wehave very frequently symptoms which

might appear to indicate extensive effusioninto the ventricular cavities ; it is not sooften that we find much evidence of the dis-ease about the brain, except that slight in-crease of serous secretion which is so com-monly found in fatal cases of pneumonia, &c.

In the treatment of these forms of diseaseI have little to add ; my purpose has beenrather to establish a discrimination, which,being determined, we shall be easily guidedin our practice by the general principles in-culcated in our elementary study.

In many cases of simple irritation the re-moval of the exciting cause will be of itselfsuiecient to cure the disorder, ere in-

flammation be established. The mere in-cision of a gum will often appear to be theeffect of magic on the child. The event,however, must mainly depend on the degreeor duration of the diarrhoea ; for if this fluxbe immoderate, the contents of the bowelswill be hurried past the lacteal orifices tothe effect of absolute exhaustion. It is, infact, of natural hvpercathartis. With re-

gard to the following exciting causes-re-tention of meconium, deficient or over-

feedtug, unwholesome milk, the irritationof dentition, the presence of worms, theremedies must be obvious. During den-tition, it is true that acute pain may, bydirectly influencing the brain and nervoussystem, exhaust the vital powers ; but evenhere, in almost every case, I have observeddiarrhoea has been a concomitant, if not aprominent symptom. In the eases producedby the application of cold, or the superficialcure of cutaneous disease, the re-establish-ment of free cutaneous transpiration, or thereproduction of the eruption, will be equallybeneficial. In general, however, the re-

covery will be expedited by the exhibitionof small doses of hydrarg. cum creta, add-

ing occasionally some aromatic powder, andone or two drops of the liq. opii sedativusat night, and after some days the employ-ment of a mild tonic. The form I wouldrecommend is the following :-

Ferri sulph. exsicc., gss ;Pot. sulph., 3iij ;Pulv. cascarill., 3ss. cap. gr. iv. ad x. b.

ter die, and a few drops of acid sulph.aromatic; added to these remedies, afew drops of laudanum should be givenin an enema of starch.

A more direct laxative is sometimes ne-cessary even, under a state of diarrhoea;for in those cases characterised by cachexia,the removal of a morbid coating, whichsometimes accumulates to an excessive de-gree over the lacteal mouths, constitutesthe laxative itself an indirect tonic.

Let me here briefly draw a distinctionbetween the condition of tabes, and thestate often consequent on weaning-thechild gradually becoming thin, but other-wise not exhibiting symptoms of an un-favourable nature. Such may be, in fact, anatural and healthy change dependent onmore solid nutriment, an increase of muscu-lar growth and power, and a diminution ofdeposition into the adipose membrane.

In speaking of the management of thesecond form, muco-enteritis, I am more

anxious again to draw the attention of themembers of this society to the nature of thedisease, than to fatigue them with a detailof treatment so plainly indicated. The de-

structive lesions, demonstrated on dissec-

tion, prove either that the disease has not

344

always been understood, or, if understood,inefficiently treated. It is in the earlystages, while the evacuations are mucousor flaky, or of the spirage green. that wemay hope to relieve. I believe that whenthe evacuations assume the appearance ofthe grey pulp, and are in great quantity,that no treatment will be available; de-struction of parts has commenced, the re-pair of which is beyond the reach ofart. In muco-enteritis, from one to fourleeches should be applied to the abdomen;the hæmorrhage assisted by the applicationof a warm bread poultice every half hour,or the child immersed in the warm bath onthe leeches falling- off. The food light andmucilaginous.

It is right for me to state that I haveexamined several cases where the perito-neal coat has been extensively diseased, andthe intestines agglutinated without muchmark of disease in the mucous membrane.These cases, however, I believe to be notcommon, but from their protracted durationthey would be as likely to exhaust life asany other form of chronic disease.The palhd or livid complexion of the

child in these diseases, has caused patholo-gists to determine that the symptoms arosefrom strumous taint of constitution and dis--ease in the mesenteric glands, and hencethey have adopted, indiscriminately, thetonic or the cordial treatment in all the stages.This T think an error the gladular suppu-ration not being the result of abstract de-bility, but an effect of destructive innam-mation on a texture endowed with deficient

vitality, incapable of resisting even blightlyincreased action.

In some of these cases, although therehad been the most striking indications of’

cerebral effusion, I have found the brain andits membranes of a perfectly healthy ap-pearance.

In conclusion, let me not undervalue thecerebral pathology of infants. Although Iconsider idiopathic meningitis in childrenas very rarely occurring, yet from its being-so readily induced by remote excitement, I inot only always regard cerebral symptomswith great jealousy, but often advise deple-tion and evaporation from the head, whenI suspect such excitement as dentition, orthe subsidence of measles or scarlatina, &c.,would be likely to induce disease about thebrain.At the conclusion of the paper, Mr.

Proctor asked the author if he had not oftenfound the liver morbidly enlarged in thisdisease.Mr. DENDY replied, that in consequence

of the great relative size of the healthy liverin infancy, he could not answer 111 theaffirmative.

Dr. W.1ilTING agreed with the author in

his division. Irritation and muco-enteritiswere often to be considered as cause andconsequence. In the first state be woulddo little more than rigidly adhere to lightdiet.Mr. DENDY concurred with Dr. Whiting

as to the value of a judicious dietetic planin all these diseases, but he thought the

exciting’ causes of the complaint were too

often overlooked.

-

November 15th.

ADMINISTRATION OF CORROSIVE SUBLIMATE

IN TINCTURE OF BARK.

THE subject of Mr. Dendy’s paper wasagain discussed this evening, but the obser-vations were of too discursive a nature to

permit of their being reported with any ad-vantage in the limited space we could affordto them. In the course of the evening thePresident (Mr. Callaway) spoke of a for-mula which he said had long been prescrib-ed with the most beneficial results, by. SirAstley Cooper. Dr. Babington, and him.self, in tabes mesenterica, especially in thosechronic affections of the alimentnrv canalwhere change of structure had commenced,viz.. a rain of the oxymuriate of mercuryin an ounce of the tincture of bark, withsome other vegetable tincture, the name ofwhich we could not ascertain. A few dropsof this were occasionally administered.An impression seemed to prevail amongst

the members, that this mixture was chemi-call incompatible, and its good, as a mer.citrial, was therefore questioned. One gen-tleman stated, however, that in a particularcase which had come under his observa.

tion, he had known salivation result fromits operation. Into this circumstance wehave instituted an experimental inquiry;and as our observations will, we believe,reconcile the conflicting opiuions, we maytake this opportunity to state them.When tincture of galls, considerably di-

luted with water, is mixed with a minutequantity of corrosive sublimate in solution,a fawn-coloured precipitate occurs, result-ing from the formation of’ a per-gallate ofmercury and tannin. A similar effect takes

place with the tincture of bark, and proceedsfrom the operation of the same affinity. Thisper gallate of mercury is dissolved, wheuheated to 98 deg., with either muriatic oracetic acid, a per-muriate or per-acetate be-ing formed, and gallic acid and tannin setfree. It will thus readily be understood,that, though chemically incompatible in the

phial, the insoluble compound is again de-composed by the acid secretions in the ali-

mentary canal, and t!wt it there operates ascorrosive sublimate, or the soluble per-acetate of mercury, as the case may be.

If, bow&ver, the corrosive sublimate be