APPENDICITIS: FROM THE STANDPOINT OF

A COUNTRY DOCTOR.

BY A. C. DAVIDSON, MD., SHARON, GA.

In presenting this paper to this intelligent and learned body of physicians and surgeons, I do not for one moment presume that any new or more interesting phase may be presented than that which has already been more elegantly written and more eloquently said about this much-talkedof and much-written-about and much-dreaded disease.

However, it is not so much with regard to the diagnosis or general pathology or with the treatment of this disease that this paper shall have to do, but it is more of a presentation of some general observations and deductions with regard to the appendix itself; and with regard to the frequency, or rather with regard to the infrequency of appendicitis as compared with the frequency of other diseases involving organs of like textural anatomy; and a presentation of some reasons why the said infrequency obtains, and of some further observations and facts, which, could they be more generally disseminated among the laity, would go far to prevent and cure that somewhat morbid mental condition which prevails to a considerable extent among the more intelligent and better classes, which for the want of a better name I have denominated appendicitiphobia.

The vermiform process is a tubelike cul-de-sac which arises from the fundus of the cecum at the juncture of the longitudinal muscular bands which pass over the cecum

and head of the colon in common with the rest of the large intestines.

It varies in length from one to four inches; its average diameter is about two lines, or the size of a No. 8 catheter, American gauge, and it is somewhat larger at its terminal or closed end. It lies somewhat in the same direction but not quite parallel with the ileum, and both enter from the same direction into the same side of the cecum, and it is sometimes provided with an imperfect valve at its open end.

It is said to be rudimentary, and is supposed to be functionless and useless. This opinion obtains among those who accept the theory of evolution as a solution of the mystery of the origin and development of all animal life. Holding to this theory, they suppose that the vermiform process is yet in its rude and undeveloped state, or just as it was when the entire human body had just come into its being, and was new and rude, and, according to their theory, was not at all possessed of its present stature, symmetry, beauty and grace, and when forsooth it had need of an appendix or elongated cecum. These opinions will be noticed again as we proceed.

The textural anatomy of the appendix does not differ materially from that of the cecum, of which it is a part. It is composed of mucous, submucous, muscular and serous membranes similar to those of the other parts of the intestinal tube. Its glandular and lymphatic structures are not unlike those of the large intestines, and its connective and areolar tissues do not differ from similar textures in other organs of the human body.

It is not, as some anatomists assert, the true base of the cecum, but is situated somewhat above, and behind the real bas-fond of that organ.

Aside from the fact that it is a blind, tubelike cul-desac, there is no reason why it should be more subject to inflammatory action than any other organic structure of similar component parts; and, notwithstanding it is a blind, wormlike tube, and having its open end situated near the base of the cecum, and therefore supposed to be liable to become the receptacle of various kinds of indigestible ingesta which enter with food substances, and otherwise, the alimentary canal, yet it is a fact that it is not more subject to inflammatory or other diseased action than are other organic structures of similar constituency.

This is the observation of a country doctor with regard to country districts.

During a period of twenty-two years, in which I have been actively engaged in a continuous and somewhat considerable practice, extending into more than fifteen counties, and having during that period of time treated more than three thousand different persons sick of the various diseases to which human flesh is heir, I have been brought in touch with only seven cases of what was supposed to be well developed cases of appendicitis.

Two of the seven were cases to which 1 was called as consultant. Five were my own cases, and of these five cases three were in the same man, occurring, however, at intervals of more than three years between attacks.

Thus it appears, and correctly, that in my own individual practice, during the time above written, I have been associated professionally with only three persons afflicted with appendicitis in a clientele of more than three thousand.

The exceeding small percentage of appendicular diseases occurring in my practice is not a peculiar nor exceptional experience, but obtains among all my rural confrères of whom I have sought statistical data.

Now, without taking cognizance of such inflammatory diseases as pleuritis, pneumonitis, bronchitis, laryngitis, pericarditis and such other inflammatory diseases as are peculiar to the thoracic region, or of such diseases as pelvic cellulitis, salpingitis, cystitis and other inflammatory diseases peculiar to the region of the pelvis; all diseases of organs whose textural anatomy is somewhat, if not altogether, similar to the anatomic structure of the appendix; and taking notice only of such inflammatory diseases as gastritis, enteric and gastro-enteric fever, ileo-colitis, proctitis and other diseases peculiar to the alimentary canal, diseased conditions of organs whose anatomic structure is not only somewhat but altogether similar to the anatomic structure of the appendix, we find in the country districts where thousands and tens of thousands of raspberries, blackberries, tomatoes, muscadines and grapes of all kinds, wild and cultivated, and other fruits abound, and which are eaten by the inhabitants indiscriminately and without restriction, regardless of the millions of seeds the said fruits contain that these last-named inflammatory diseases oсcur more than fifty-fold more frequently than does appendicitis.

Now, should these data taken from my own individual experience and from the experience of my rural medical confrères be objected to upon the ground of a possible inaccuracy of diagnosis, then from this objection to these experiences I appeal to the vital statistics of the great cities.

Taking Philadelphia as a fairly representative city and its vital statistics as a fair sample of the vital statistics of the other great cities, and taking it for granted that these statistics are correct, and that those physicians from whose reports the aforesaid vital statistics were tabulated made no mistake with regard to diagnosis, and that a greater per cent. of cases of appendicitis recovered in their hands than recovered from any other diseases treated, yet by reference to these same statistics as they appear from week to week in that very much up-to-date medical weekly, the Philadelphia Medical Journal, we find that not many more deaths from appendicitis have occurred in the thousand inhabitants of the great cities than have occurred in the thousand inhabitants in the country districts, as above written. Again, by reference to the aggregation of the vital statistics of the principal cities of the United States as taken from the United States census reports, 1889-90, we find that less than one-half of one per cent. of all deaths therein reported were caused by appendicitis. But this comparative infrequency of deaths from appendicitis is not exceptional nor peculiar to the country districts and cities of the United States. Mulhall, in his tabulation of the vital statistics of European countries (1896), does not mention any deaths from appendicitis at all.

From these necrological data as culled from different sources, we find that the percentage of deaths occurring from appendicitis, in the great cities as well as in the country districts, is exceeding small as compared with deaths occurring from other inflammatory diseases involving organs whose textural anatomy is not altogether dissimilar to the anatomic structure of the vermiform appendix.

Therefore, from a consideration of my own experience and from the experience of those of my medical brethren whose duties like my own abound in the country, and from a review of the statistics of the great cities, as above written, I am led to the conclusion that notwithstanding the appendix is a blind, wormlike tube, and having its open end situated near the base of the cecum, and therefore supposed to be liable to become the receptacle of numerous and variable indigestible ingesta which enter with food substances, and otherwise, the alimentary canal, yet it is a fact that it is not more subject to inflammatory or other