THE GENERAL PRACTITIONERS OF ENGLAND: THEIR COLLEGIATE RIGHTS AND DUTIES
99 similar to bleeding, which, we are told, does not reduce pressure. Then we may get the following associations on combinations-namely, increased pressure along with an increased flow of blood into the veins, and increased pressure with a diminished flow; diminished pressure with increased flow, and diminished pressure with a diminished flow of blood into the veins. These combinations are very puzzling until the two factors are separated, when they become more easy to understand. Thus,
... tand. Thus, increased pressure, the result of an increased quantity of blood, is accompanied by an increased flow into the veins; but increased pressure, the result of contraction of the artries, is accompanied by a diminished flow, and diminished pressure, the result of the arteries pressing less on the blood (i.e" dilatation) is accompanied by an increased flow; but a diminished pressure the result of less blood is accompanied by a diminished flow. Without this distinction it is somewhat difficult to see what necessary connexion there is between pressure and flow, but with this distinction it is apparent. The last point I will discuss is the effect of section of the renal nerves on pressure in the vessels of the renal glomeruli; this section causes the renal arteries to dilate, and both Foster and Brunton state that this dilatation leads to an increased pressure in the vessels of the glomeruli, and Foster further states that this occurs, although the pressure in the renal arteries is lowered. This is very difficult to follow, and where the increased pressure comes from I cannot conceive. It cannot come from the relaxed arteries, whose tonos or tension is gone; it cannot come from peripheral resistance, for that is gone with the section of the nerves; and peripheral resistance being gone, pressure from behind cannot cause it, as the renal arteries, with lowered pressure, intervenes. In my opinion section of the renal nerves does not cause increased pressure in the vessels of the glomeruli, although more blood passes through them. Space forbids me discussing other interesting problems, and, in conclusion, if my criticisms of such eminent authorities as Foster and Brunton are radically wrong, I can only express my sorrow for it,and spend two or three months more in trying to overcome the intricacies of vascular pressure. I remain, Sirs, your obedient servant, East Greenwich, Nov. 23rd, 1886. To the Editors of THE LANCET. SIRS,—An instance of suppuration in the vermiform appendage of the caecum causing enteritis and peritonitis is so rare that I hope you may deem it worthy of record in the pages of THE LANCET. A man aged forty-two, occupying the position of an in-door servant as hall-porter, was seized with severe pain in the abdomen, vomiting, and such prostration that he was scarcely able to stand. On seeing him the following morning, 1 found him with tenderness spread all over the abdomen and considerable tympanites. The tenderness was more marked on the right half of the abdomen than on the left, and there was one spot, about an inch to the right of the umbilicus, where the pain was intensified; here, too, there was some slight bulging of the abdominal walls, but no additional hardness. The pulse was 80, and the temperature normal. An enema was given of gruel and castor oil, which was expelled free from fæcal matter; a hot linseed poultice was placed all over the abdomen, and changed every four hours; a grain of extract of opium was administered every six hours; simple farinaceous nutriment was given in small quantities, but was ultimately all rejected. On the third day the pulse remained at 80, and the temperature continued normal; the abdomen was less tympanitic, and less tender; the vomiting continued, and there was a total inability to retain nourishment by the stomach. Nutrient enemas of an extract of beef, with port wine, were now administered every eight hours, and retained; and the opium was continued, though less frequently. On the fourth day the pulse had risen a little, but the temperature remained normal; the bowels acted freely, the excretion consisting of yeast-like semisolid material; the tympanites and tenderness both lessened, and the bulging to the right of the umbilicus had disappeared; but the skin had become bedewed with a cold clammy perspiration, and there was great prostration. On the fifth day the abdominal symptoms had somewhat abated ; the bowels acted again, but violent retching continued, and the vomit had become distinctly stercoraceous; the pulse rose to over 100, and the temperature to 101° ; the nutrient enemas and opium were continued ; but the cold and clammy perspiration did not abate. On the sixth day the abdominal symptoms were less severe ; the bowels acted again, with evident relief to the abdomen ; but the retching continued, and the vomited matter was still stercoraceous. The chief distress was now referred to the epigastrium, apparently caused by the violent retching. Cotton-wool was substistituted for the poultice; the nutrient enemas and opium were continued. On the evening of the sixth day sym-. ptoms of collapse set in, and death ensued in the night. , An examination of the abdominal cavity was made twentyfour hours after death; there was subacute inflammation of the peritoneum and of the intestines, increasing in degree towards the cæcum, but was more marked in the small than in the large intestines. The discolouration was most marked around the vermiform appendix. The appendix was very discoloured at its base, as if it had been constricted, but no band could be detected. The body of the appendix was distended, which, on being laid open, was found to contain a small quantity of sanguineous pus, but no other foreign material could be detected. A gooseberry-pip, a cherrystone, a mustard-seed, the small pips of a fig, and a piece of hard fæcal matter have been known to intrude into the vermiform appendix, and set up fatal enteritis and peritonitis, but I cannot find any case of suppuration recorded. As the appendix exists only in human beings, in the ourang-outang, and in the wombat, but, as far as is known, in no other animal, its presence is probably not essential to life. The question naturally arises, would removal by operative interference afford relief in cases similar to the one recorded when the symptoms pointed sufficiently to the seat of mischief ? I am, Sirs, yours obediently, I Wokingham, Jan.