Preventable Diseases

by Woods Hutchinson

If we want something distinctly human to be proud of, we may take the appendix, for man is the only animal that has this in its perfection. A somewhat similarly shriveled last four inches of the cæcum is found in the anthropoid apes and in the wombat, a burrowing marsupial of Australia. In some of the monkeys, and in certain rodents like the guinea-pig, a curious imitation appendix is found, which consists simply of a contracted last four or five inches of the cæcum, which, however, on distention with air, is found to relax and expand until of the same size as the rest of the gut.

The most strikingly and distinctly human thing about us is not our brain, but our appendix. And, while recognizing its power for mischief, it is only fair to remember that it is an incident and a mark of progress, of difficulties overcome, of dangers survived. In all probability, it was our change to a more carnivorous diet, and consequently predatory habits, which enabled our ancestors to step out from the ruck of the "Bandar-Log," the Monkey Peoples. An increase in carnivorousness must have been a powerful help to our survival, both by widening our range of diet, so that we could live and thrive on anything and everything we could get our hands on, and by inspiring greater respect in the bosoms of our enemies. Let us therefore respect the appendix as a mark and sign of historic progress and triumph, even while recognizing to the full its unfortunate capabilities for mischief.

But what has this ancient history to do with us in the twentieth century? Much in every way. First, because it furnishes the physical basis of our troubles; and second, and most important, because, like other history, it is not merely repeating itself, but continuing. This process of shriveling on the part of the appendix is not ancient history at all, but exceedingly modern; indeed, it is still going on in our bodies, unless we are over sixty-five years of age.

In the first place, we have actually passed through two-thirds of this process in our own individual experience.

At the first appearance of the cæcum, or blind pouch, in our prenatal life, it is of the same calibre as the rest of the intestine, and of uniform size from base to tip. About three weeks later the tip begins to shrivel, and from this on the process steadily continues, until at birth it has contracted to about one-fifteenth of the bulk of the cæcum. But the process doesn't stop here, though its progress is slower. By about the fifth year of life the stem of the cæco-appendix pipe has diminished to about one-thirtieth of the size of the bowl, which is the proportion that it maintains practically throughout the rest of adult life. For a long time we concluded that the process was here finished, and that the appendix underwent no further spontaneous changes during life; but, after appendicitis became clearly recognized, a more careful study was made of the condition of the appendix in bodies coming to the post-mortem table, dead of other diseases, at all ages of life. This quickly revealed an extraordinary and most significant fact, that, while the appendix was no longer decreasing in apparent size, its internal capacity or calibre was still diminishing, and at such a rate that by the thirty-fifth year it had contracted down so as to become cut off from the cavity of the cæcum in about twenty-five to thirty per cent of all individuals. By the forty-fifth year, according to the anatomist Ribbert (who has made the most extensive study of the subject), nearly fifty per cent of all appendices are found to be cut off, and by the sixty-fifth year nearly seventy per cent.

This explains at once why appendicitis is so emphatically a disease of young life, the largest number of cases occurring before the twenty-fifth year (fifty per cent of all cases occur between ten and thirty years of age), and becoming distinctly rarer after the thirty-fifth, only about twenty per cent occurring after this age. As soon as the cavity of the appendix is cut off from that of the intestine, it is of course obvious that infectious or other irritating materials can no longer enter its cavity to cause trouble, although, of course, it is still subject to accidents due to kinks, or twists, or interference with its blood-supply; but these are not so dangerous, providing there be no infectious germs present.

Here, then, we have a clear and adequate physical basis for appendicitis. A small, twisted, shriveling spur or side twig of the intestine, opening from a point which has become a kind of settling basin in the food-tube, its mouth gaping, as it were, to admit any poisonous or irritating food, infectious materials, disease-germs, the ordinary bacteria which swarm in the alimentary canal, or irritating foreign bodies, like particles of dirt, sand, hairs, fragments of bone, pins, etc., which may have been accidentally swallowed. Once these irritating and infectious materials have entered it, spasm of its muscular coat is promptly set up, their escape is blocked, and a violent inflammation easily follows, which may end in rupture, perforation, or gangrene.

Not only may any infection which is sweeping along the alimentary canal, thrown off and resisted by the vigorous, full-sized, well-fed intestine, find a point of lowered resistance and an easy victim for its attack in the appendix, but there is now much evidence to indicate that the ordinary bacteria which inhabit the alimentary canal, particularly that first cousin of the typhoid bacillus, the colon bacillus, when once trapped in this cul-de-sac, may quickly acquire dangerous powers and set up an acute inflammation. It is not necessary to suppose that any particular germ or infection causes appendicitis. Any one which passes through, or attacks, the alimentary canal is quite capable of it, and probably does cause its share of the attacks.

Numerous attempts have been made to show that appendicitis is particularly likely to follow typhoid fever, rheumatism, influenza, tonsilitis, and half a dozen other infectious or inflammatory processes. But about all that has been demonstrated is that it may follow any of them, though in none with sufficient frequency or constancy to enable it to be regarded as one of the chief or even one of the important causes of the disease.

One dread, however, we may relieve our anxious souls of, and that is the famous grape-seed or cherry-stone terror. To use a Hibernianism, one of our most positive conclusions in regard to the cause of appendicitis is a negative one: that it is not chiefly, or indeed frequently, due to the presence of foreign bodies. This was a most natural conclusion in the early days of the disease, since, given a tiny blind pouch with a constricted opening gaping upon the cavity of the food-canal, nothing could be more natural than to suppose that small irritating food remnants or foreign bodies, slipping into it and becoming lodged, would block it and give rise to serious inflammation. And, moreover, this a priori expectation was apparently confirmed by the discovery, in many appendices removed by operation, of small oval or rounded masses, closely resembling the seed of some vegetable or fruit. Whereupon anxious mothers promptly proceeded to order their children to "spit out," with even more religious care than formerly, every grape-seed and cherry-stone. The increased use of fresh and preserved fruits was actually gravely cited, particularly by our Continental brethren, as one of the causes of this new American disease. Barely ten years ago I was spending the summer in the Adirondacks, and was bitterly reproached by the host of one of the Lake hotels, because the profession had so terrified the public about the dangers of appendicitis from fruit-seeds that he was utterly unable to serve upon his tables a large stock of delicious preserved and canned raspberries, blackberries, and grapes which he had put up the previous years. "Why," he said, "more than half the people that come up here will no more eat them than they would poison, for fear that some of the seeds will give 'em appendicitis." This dread, however, has been deprived of all rational basis, first, by finding that many inflamed appendices removed, after the operation became more common, contained no foreign body whatever; secondly, that many perfectly healthy appendices examined on the post-mortem table, death being due to other diseases, contain these apparently foreign bodies; and thirdly, that when these "foreign bodies" were cut into, they were found to be not seeds or pits of any description, but hardened and, in some cases, partially calcareous masses of the fæces.