EDITORIAL

Chronic Appendicitis

Once Again T I-IE CLI~ICIAX, it mus t be admit ted , has ahvays t rea ted the

pa tho logis t a bit unfai r ly . I see no reason to change t h i n g s - - the pa tho logis t genera l ly deserves i t - - b u t when it comes to the appendix , and especially chronic appendici t is , there has been a serious and r ecu r ren t clinical m i s a p p r o p r i a t i o n of pathologic in- fo rma t ion for which the clinician might as wei1 confess responsi- bility. Once again, it seems, the clinician is in danger of fal l ing into the t r ap of chronic appendici t is , in d i s rega rd for clear-cut medical h is tory . E x a m i n a t i o n of the l is t ings of the medical indexing serv- ices du r ing the pas t five years shows, pa r t i cu la r ly in the fore ign l i tera ture , that , a f ter m a n y ) 'ears of deserved oblivion, the diagno- sis of chronic appendic i t i s is mak ing a comeback.

The clinician has ahvays ins is ted that the pa thologis t must never d raw conclusions which are at var iance wi th the clinical facts. This is quite obviously a p re requ is i t e to s t ra igh t pathologic think- ing. At one t ime the pa thologis t rebelled at this, largely because he was in the habi t of over looking the fact that the aging process begins at birth. He tended to make his ana tomic compar isons with the t issues of the newborn, as a sort of pure base-line, unadul ter - a ted by the noxious influences of this ha rd life. But it has since be- come clear tha t successful deve lopment in the face of a life which is h a r d is the first requis i te of h e a l t h - - h e a l t h depends on a cer ta in degree of success in mee t ing these noxious influences. A proper definition of health, it can be agreed, mus t include a little more than th is : I t mus t also encompass a cer ta in abil i ty of the t issues to re- spond in a prescr ibed manne r to insul ts received.

I f a definition of clinical hea l th is to sanct ion inclusion of clini- cally cured diseases, the clinician mus t u n d e r s t a n d tha t at t imes it mus t to lera te r a the r p r o f o u n d ana tomic abnormali t ies . Thus it is wi th the append ix and wi th chronic appendici t is . Evidence of cure - - t h e scars of d i s e a s e - - m u s t not, of course, include changes which affect funct ion, resistance, or adaptabi l i ty . I t is with this point

AMERICAN JOURNAL OF 594 DIGESTIVE DISEASES

Editorial

that the clinician has his problem, as he examines the his topathol- ogy of the resected append ix and tr ies to make a corre la t ion wi th the clinical events of the recent past . The problem largely revolves about the amoun t of wear and tear tha t can be evidenced by an ap- pendix which has never caused clinical illness.

The appendix at b i r th has a wide lumen, and, as the best insur- ance agains t obst ruct ion and deve lopment of acute inf lammation, this fea ture explains why acute appendic i t i s is so ra re in the neo- nate. Wi th in two years , however, the submucosal lymphoid t issue has developed to a g rea t degree, reduc ing luminal d iamete r and creat ing a cause for the sudden increase in the incidence of acute appendici t is . The o p p o r t u n i t y for subclinical inf lammat ion and fibrosis begins immediate ly . Tha t both actual infect ion of the ap- pendiceal wall and secondary in f lammatory response within the lymphoid t issue to c i rcula t ing noxious substances are common can be readi ly agreed upon ; tha t the resu l t ing i n t r a m u r a l fibrosis can- not later be used as an explanat ion for clinical illness has been more difficult to accept. The pressures the clinician feels in this re- ga rd have to do with his na tu ra l compuls ion to end up wi th an organic diagnosis, if that is at all possible. " C h r o n i c appendi- c i t i s ," like gastr i t is , p ro lapse of the gast r ic mucosa, and m a n y others, becomes a diagnosis of enforced expediency.

EDDY D. P~ER, ~I.D. Second General Hospital

A.P.O. 18o, New York, N. Y.

NEW SERIES VOL. 2, NO. I0, 1957 595