The Present Status of Appendiceal Diagnosis

Abstract

The papers on appendiceal pathology, in 1886, and the reports of the first operation for the removal of the appendix, in 1887, had far-reaching effects. The spectacular results in a certain percentage of the cases led to operations for acute or chronic appendix for a wide range of abdominal symptomatology, either real or imagined. The inevitable reaction followed and the pendulum swung far back until operation for any except acute appendices was condemned. The diagnosis of chronic appendicitis was disputed by many surgeons. There must be a calm or a cyclone—no gentle breeze was tolerated. My work in diagnosis began at a time when, of patients entering the clinic in which I worked, nearly 50 per cent had previously had their appendices removed. At least one-half of these had received no admitted benefit from the operation. Routine X-ray examinations of 6-hour and immediate meal, 24-hour, 48-hour and enema, revealed few appendices outlining. Naturally we accepted the prevalent view and in those early years I remember only two diagnoses of appendicitis being made. Yet from time to time reports filtered back of patients who had suffered removal of ruptured appendices at later dates. Re-checking of our records revealed no sure criterion for a diagnosis. Upon seeking the opinions of others on this subject which was of tremendous interest to us, we found a wide variation of opinion among roentgenologists. I well remember a discussion in which I was interested to hear one roentgenologist maintain that all appendices which did not outline were pathologic and should come out. His opponent was equally certain that any appendix that did outline was pathologic and should come out. We decided that more work was necessary before the subject could be closed. Our efforts to obtain evidence redoubled. 110re careful and more frequent screenings of the emptying cecum revealed filling in the majority of appendices. Careful palpation discovered tenderness often appearing at a screening although it had been absent on previous exposure. In some cases this pain was referred to the region of the solar plexus and the patient compared it to digestive discomforts that had been complained of in his history. At about this time A. L. Gray, M.D., of Richmond, Virginia, reading in Washington, D. C., on “Cyclic Vomiting in Children,” traced the etiology to the appendix. He stated his belief that children showing an appendix with an emptying time of over 100 hours had a pathologic appendix. In cases in which the appendix was removed, the patients were relieved of the vomiting. Rejoicing that this work in children coincided with our studies of adults, we continued our investigation. In checking the literature we found a gradually increasing number of articles on this subject.