Acute appendicitis

Editor—Over 40 years ago, I studied the clinical pathology of the appendix and the epidemiology of appendicectomy. I would like to comment on four complementary issues.¹ Firstly, around 1960 the 4/1000 death rate ranged from 1/2600 for uncomplicated appendicitis in young adults, to 1/9 for patients older than 50 with a perforated appendix. Death rates for male patients were double those for female patients. Deaths from a normal appendicectomy were 1/5000 in young adults.² In my own study of 1412 appendicectomies, surgeons differed over whether to risk removing normal appendixes or leave abnormal ones in, and deaths from higher and lower operative approaches balanced almost exactly. However, morbidity from the more conservative approach was higher due to more readmissions, and more patients continued to complain of pain in the right iliac fossa.³

Secondly, 37 of 45 patients with recurrent or chronic appendicitis had iron deposits in their appendixes, a histological finding that correlated with recent pain in the right iliac fossa.⁴ In 119 patients with mesenteric adenitis, cure by surgery was also likely for those whose appendixes were positive for iron. Is the concept of neuroimmune appendicitis a helpful addition to an already idiosyncratic diagnostic area?

Thirdly, I found no evidence that appendicitis ran in families, but appendicectomy did. Another indication that appendicectomy was a decision sometimes influenced by non-biomedical factors was that surgeons of all operative approaches were more likely to remove appendixes from nurses and from colleagues' children.⁵

Fourthly, in 65 of 870 certified deaths from appendicitis, no evidence was found of either appendicitis or an appendicectomy. In 88 of my own series of appendicectomies, discharge classifications of appendicitis were entered despite no histological evidence of appendicitis.

Two decades later, I found that the same issues applied to the use of antibiotics by general practitioners. Whether in surgery or in general practice, any theoretical model for clinical practice must allow for the interaction of both biomedical and behavioural science. The challenge to clinical practice of modern evidence based medicine and clinical guidelines is to find out how to celebrate and incorporate the right balance between these two interdependent sciences to counter increasingly discontinuous and target centred care.