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a triple effect : it preserved the erum, it acted as a sedativeto the mucous membrane of the rectum, and it also causedthe child to sleep for an hour or two after the adminis-tration of the injection, thus facilitating its retention andhence its assimilation. 360 cubic centimetres of serum, 360cubic centimetres of milk, and 48 grammes of carbohydratewere introduced during the 24 hours, which diet possessesan energy value of over 500 calories, which is not much shortof three-quarters of what is necessary for a child three anda half years of age. When the pulse became feeble and theheart sounds assumed an embryonic type a few minims oftincture of nux vomica and of digitalis were added to thenutrient enemata. The efficiency of a rational rectal dietcontaining materials which we know can be absorbed by thelarge intestine was proved by the very slight loss in weightof the patient in spite of no food being given by the mouthfor 10 days.

To Dr. H. D. Rolleston I am indebted for kindly criticismin writing out the case and for assistance in the recentliterature of the subject. Mr. Robert MacQueen was goodenough to take daily notes of the case and to draw two ofthe diagrams, and without his able assistance it would havebeen impossible for me to have recorded the case.Wimpole-street, W.

PURPURA FULMINANS FOLLOWINGSCARLET FEVER.

BY HUBERT E. J. BISS, M.A., M.D. CANTAB.,D.P.H. EDIN. & GLASG.,

ASSISTANT MEDICAL OFFICER TO THE GROVE FEVER HOSPITAL.

THE diagnosis of the exceedingly rare condition fromwhich the patient whose case is narrated below suffered isnot by any means clear. It seems to me to correspond moreclosely to the condition which is described by Henoch underthe name of purpura fulminans than to any other with whichI am acquainted. It is noticeable, too, that one of the twocases related by him occurred after scarlet fever, as did alsoone of two cases related by Strom and Arctander. Now,hæmorrhagic scarlet fever, as described in some works, is ofgreat rarity in this country at the present time ; it isdoubtful, indeed, if extensive cutaneous and subcutaneoushaemorrhages ever occur in the early stages of the disease ;whether the cases related in those works, in fact, were notactually cases of haemorrhagio diphtheria. Hoemorrhagesinto the skin and subcutaneous tissue are met with not veryinfrequently in association with obstinate suppurativelesions after scarlet fever, such as chronic suppurativelymphadenitis, suppurations in joints, and suppurations in andabout the temporal bone. No such lesion obtained in thiscase. The child had a very severe attack of scarlet feverwhich did not present any unusual features and convalescenceappeared to be established. He still had some ulceration oft.he soft palate, it is true, but the other symptoms had eitherpassed off or had much abated, the temperature was settlingdown, and he was bright and comfortable. At this pointcutaneous haemorrhages in enormous abundance took place,accompanied by hasmatemesis, bloody stools, and oozingfrom the gums. In 36 hours from the appearance of the first

haemorrhages he was dead. The chief feature of the post-mortem examination was the state of the kidneys. Thesewere transformed almost entirely into fat, a little blood-clotbeing found in the calices. This blood-clot, too, must havebeen very recent, as none was found lower down the

urinary tract, even the urine in the bladder beingfree from blood. The kidney was a very differentone from that associated with any variety of scarletfever and no sign or symptom of nephritis occurredduring life, except that albumin in small quantity waspresent in the urine for one day soon after admission. The

change would appear to have been far more of the nature ofan acute degeneration than of an inflammation, the homo-geneity of the condition being very different from thesectional infiltrations seen in either the septic or glomerulartype of scarlatinal kidney. No renal phenomena were notedby Henoch in the necropsies of his cases and Strom andArctander do not state whether post-mortem examinationswere made in their cases.The sudden occurrence of these widespread hæmorrhages

suggests a very acute toxaemia or blood infection due to theelaboration oi some toxic substance or the supervention ofsome fresh organism, but what the nature of such body mayhave been and what determined its appearance at this periodof the disease are speculations beyond the range of legitimatetheorisation. A conceivable criticism is that these abundant

haemorrhages were but an advanced stage of the punctiformheamorrhagic rash that occasionally follows the administra-tion of animal sera, for diphtheria antitoxic serum had beengiven to this child in error. That this should be so isin the highest degree improbable, for not only has such anoccurrence never been noted after the many thousandadministrations that have come within one’s purview, butthis particular serum was used for injection into manychildren in the hospital without any analogous phenomenaensuing.The clinical and pathological features of the case may be

briefly summarised as follows :A boy, aged three and a half years, was admitted into the

Grove Fever Hospital on May 16th, 1902, certified to besuffering from diphtheria and on this supposition was givenan injection of serum containing 24,000 units of diphtheriaantitoxin. On examination, however, his trunk and limbswere found to be covered with a coarse, blotchy, punctiformerythematous rash ; the throat was much reddened andvery cedematous ; the tonsils were coated with slimy exu-dation ; the nasal mucous membrane was turgid andcovered with muco-purulent discharge ; the submaxillarylymphatic glands were considerably enlarged ; and the tonguewas dry and clothed with fur. Culture of the tonsillarexudation presented an abundant growth of streptococci.He was very ill till the 21st, when the temperature, whichhad been continuous at 103° F., fell to 990, and there wasa general abatement of the symptoms. On that eveninghe became more feverish (the temperature being 102.4°),and on the next day an urticarial rash appeared on thetrunk, due doubtless to the previous injection of serum.

Double otitis media, diarrhoea with green stools, and free

general desquamation ensued. On the 25th a furthereruption, a macular, purplish-red one, was noticed about theknees, the ankles, and the elbows. By the 29th he was muchbetter ; the glandular swellings had almost disappeared andthere was no rash or diarrhoea. Bilateral otorrhoea, how-ever, remained, and there was a little rhinitis, whilst anulcer of the size of a threepenny-piece was found at thejunction of the soft palate and the right anterior pillarof the fauces, though the tonsils were free from exuda-tion and the tissues of the throat were but little swollen.From this time he improved rapidly till June 4th, notwith-standing that the temperature still fluctuated between101° and 99°. On that day a vast number of pin-pointhaemorrhages were seen in the skin of both sides of thetrunk, whilst the next morning the trunk and limbs wereliterally covered with these points, the upper extremities

being so densely set with them as to appear almost uniformlypurple. There were but few on the face, except on theinner sides of the eyelids where they were about the size ofgrape-stones. Blood oozed from the gums, but there were nosubcutaneous or subconjunctival haemorrhages. His generalcondition was markedly worse. He vomited half a pint ofred blood twice during the day and towards the evening hepassed about that quantity of brightish-red blood per rectum.He died soon afterwards.

Necropsy.-At the post-mortem examination, which wasperformed 30 hours after death, the cutaneous haemorrhageswere abundantly apparent and blood-clot encrusted the lips,the nose, and the anus. Under the visceral pericardium andpleurae a few punctiform haemorrhages were seen, similar

points being present under the endocardium of the leftventricle. The pleurae each contained a few drachms of clear,pink fluid and the trachea and bronchi similarly-tinted frothymucus. The stomach showed many medium-sized, sub-mucous haemorrhages, and both it and the intestines, whichlatter were deeply cyanosed, contained chocolate-colouredfluid ; crimson, viscous blood filled the rectum. Beyondthickening and ulceration of the tissues of the throat nothingelse remarkable was seen till the urinary system was exa-mined. Both kidneys were a little enlarged, but their

capsules stripped readily. On section the parenchyma wasfound to be transformed almost entirely into fat, whichstained readily with osmic acid but not at all with iodinesolution. There was no differentiation into cortex andmedulla and a few faint pink streaks alone suggested the

direction of the tubules. Several of the calices contained a

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little blood-clot but none was found in the pelves or ureters.The bladder was distended with clear, yellow urine, whichgave no haemoglobin reaction when tested with tincture ofguaiacum and ozonic ether.

I am indebted to Dr. J. E. Beggs, medical superintendent,for permission to publish this case.Tooting, S.W.

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SOME ADDITIONAL REMARKS ON THEETIOLOGY AND DIAGNOSIS OF ACUTE

DILATATION OF THE STOMACH.

BY H. CAMPBELL THOMSON, M.D., F.R.C.P. LOND.,ASSISTANT PHYSICIAN TO THE MIDDLESEX HOSPITAL.

IN my recently published book on the subject of acute

dilatation of the stomach I have discussed at some lengththe different theories which have been put forward to accountfor the disease, and while in no way denying that some casesmay be obstructive in origin I inclined to the belief that a

primary paralysis of the organ must be regarded as theunderlying cause in the majority of the cases. Those who

support the theory that obstruction is the main cause con-

sider that under certain conditions within the abdomenthe superior mesenteric artery may exercise a constrictingforce upon the duodenum, and the conditions necessarythus to produce this constriction are thought to be fulfilledby the displacement of collapsed intestine into the pelvisby which such a tension is put upon the mesenterythat the cord-like superior mesenteric artery becomes con-

verted into a constricting band and obliterates the lumenof the duodenum. There are many arguments againstthis theory which I have discussed elsewhere and need notagain refer to here, but the main objection to the adoption ofthis view lies in the fact that the point at which distendedbowel passes into collapsed bowel varies in different cases

coils of intestine is shown in the accompanying figure whichis reproduced trom a photograph taken at the time of thenecropsy, and it is obvious that in this case the superiormesenteric artery cannot be considered as the constrictingforce nor were there any signs of any other constrictingforce having been present.

In the absence of any constriction a primary paralyticcondition woulrl seem to give an adequate explanation ofthis case, as it does in so many others, and, as I have beforepointed out, there is no obvious reason why, if a primaryparalysis is assumed to take place in the stomach, we -houldsuppose that paralysis to be necessarily limited to thestomach. The nervous connexions between the vagi andabdominal plexuses are very complex, and it seems reasonableto suppose that the paralysis which involves the stomach

may in different cases extend variable distances along theintestine and such variable extension would adequatelyexplain the fact that the distended bowel terminates atdifferent levels. Reference in my former writings will alsobe found to the probable relationship between acute dilata-tion of the stomach and the paralytic distension of the intes-tines which occurs during cases of acute peritonitis. It is,of course, common, and indeed usual, to find the intestinesdistended in cases of peritonitis and there can be littledoubt that the distension is due to paralysis of the gutwalls consequent to the inflammation of the peritoneum.While in these cases distension of the intestine is

usually the predominating feature, both during life andafter death, the necropsy often shows that the stomachhas also to some extent participated in the conditionand occasionally the gastric symptoms form the most

prominent feature of the case and may for the time evenmask all the symptoms of the underlying peritonitis.This fact assumes considerable importance when it is remem-bered that peritonitis is the condition which clinically mostclosely resembles acute dilatation of the stomach and forwhich many primary cases of the latter have been mistaken.We have thus in every case in which symptoms of acutedilatation of the stomach occur after an abdominal opera-tion, or under other conditions in which peritonitis would

Acute dilatation of the stomach and upper eight feet of intestine.

which it obviously would not do if the situation of theconstricting force were a constant one as it would be in thecase of the superior mesenteric artery. I quoted cases in mybook showing that sometimes only the first part of theduodenum shared in the dilatation while in others thedistension extended some inches along the jejunum. Morerecently I have had an opportunity of making a necropsyupon a case in which acute dilatation of the stomach wasaccompanied by distension of eight feet of small intestine,the distension passing abruptly into collapsed bowel at thatpoint. The appearance of the distended stomach and upper

be likely to arise, to decide whether the dilatation is a

primary condition or whether it is only the predominatingfeature of a general peritonitis. A case which I recentlyhad an opportunity of seeing with Dr. Comyns Berkeleywell illustrates this condition and also the difficulty whichone may have in arriving at a correct diagnosis when thereis a possibility of peritonitis co-existing, although there

may be no obvious reasons which would leadone to suspectits presence.The patient was a female, aged 32 years, and had

previously had five children. SLe had passed uneventfully