Talk:Paper - Studies in the development of the opossum 5 (1920)

Racial And Sexual Differences In The Appendix Vermiforaiis

Henry Bayon

Department of Anatomy of Tulane University

About thirty years ago the appendix had practicalh' no history, either physiological or pathological.

Howard Kelly in his extensive work on the vermiform appendix and its diseases, recalls that only in 1824 was the appendix recognized as an organ susceptible to disease arising primarihin its own structure, although mention was made of isolated cases such as ]\Iestiviei's recorded in 1759 in which a postmortem examination revealed a pin (t)ncealed in the appendix, which had caused inflammation resulting in the death of the patient. This and other similar cases related in Kelly's work show that even in the eighteenth century the appendix was recognized as susceptible to inflammatory lesions, but it was not until 1886 that the appendix was placed in the category of organs susceptible to surgical disease. From that time the daily harvest of appendices has steadily increased. At the beginning of that period we hear Frederick Treves, one of the pioneers of appendectomy, clamoiing against the indiscriminate removal of the appendix, which he brands as a needless and illogical recklessness.

Since that time a number of speculative statements have appealed regarding the purpose of the appendix, usually more or less fanciful and sometimes positively grotesque. From the high otiice of abdominal tonsil we find it elsewhere relegated to the abject role of the ordinar}^ mechanical grease cup. In studying the minute structure of the appendix, it is true that large numbers of lymphocj'te accumulations are found within its walls, but at best these amount to little compared with similar accumulations found elsewhere in the intestinal canal and are in no way diff'erent from the solitary and aggregated lymphatic nodules.

241

242 HENRY BAYON

Nceilless to say that the grease-cup theory (imls no support from whatever aiiRlo the organ is vioweil. It evidentl}' originated in 174^ from an old theory of J. Vosse, who ohiimed that the ghmds of the cecum were not sufficient to moisten its contents antl that tlie function of the apjiendix was to provide additional secretion.

It is not the jjurposenf tlie ])resent study, however, to discuss the function of the api)endix nor the conditions which call for its removal. It was undertaken with a view to possible difTerences in .structure, both as to race and as to sex.

In considering disea.se of the appendix, the following (juestions suggested them'selves: Is appendicitis more frequent in the white race than in the negro? Is the disease more prevalent in one or the other of the sexes? .\nd if there are racial and sexual differences, is there anything in the structure of the appendix to account for such difTerences?

The first question, if records and Surgical experience are given consideration, is answered decided!}' in the affirmative. The statistics, however, on this, as unfortunately on a great many other subjects, are totally unrelial)le, even though tabulated intelligent h' and in good faith.

The eagerness displayed bj' the medical i)rofession in coming before the public, both in print and in lecture, no doubt in a great manj- instances with very laudable intent and good effect, places Avithin reach of the more intelligent hwman much of the interpretation of his own ills and jiains. He seldom ignores the signs and symptoms of appendicitis. As a result, the first tinge of pain in the right iliac region will sound a loud note of warning, followed b}' a rush to the surgeon, who at once proceeds to remove the aj)pcndix, in which postoperative examination frequently reveals little or no inflammatory change. This statement, however, is made with due regard to surgical prudence svhich takes no chances in a condition where prompt treatment means so much to the patient's safety. At this juncture it may not be inappropriate to refer to the opinion so frequently exjire.ssed, that apjiendicitis is on the increase. That the number of appendectomies has increased there can be no question, but that appendicitis is increasing is more than doubtful.

RACIAL DIFFERENCES APPENDIX VERMIFORMIS 243

In contrast with the alertness of the better classes and their readiness to part with an offending organ, is the ignorance and apathy of the poor negro concerning his disease and the counterindifference of his medical attendant. Acute indigestion or heart failure are con^-enient and readj' forms for his death certificate. Acute gangrenous appendicitis maj' have caused his death, but his tardiness in seeking medical aid or the lack of interest of his doctor, who comes in when the patient is dying or dead, are in many instances responsible for the error in diagnosis. Hence a possible flaw when records are considered, in passing judgment as to the racial susceptibility to appendicitis.

But if statistics are negative in deciding susceptibility, might there not be some structural peculiarity which would make certain appendices more vulnerable than others? Some time ago, in a casual examination of appendices in the dissecting-room, I was struck with the stout musculature of the negro organ as compared with the flabby membranous appearance of the white appendix. Obviously, a fecal stone or a foreign bodj^ would have far less chance of becoming impacted or retained in a robustly muscular appendix with active peristalsis possible than in one whose weaker walls would not only fail to rid the organ of its offending contents, but in consequence of the organ's easier distention would favor the storing up of enormous numbers of pathogenic bacteria.

Hoping to arri\-e at some tangible facts regarding structm-e which might cast some light on racial and sexual peculiarities, I have examined 100 appendices and tabulated them according to race and sex. The specimens emploj^ed comprised 53 negro appendices, 31 male and 22 female, and 47 wliite appendices, 11 nude and 36 female.

METHOD OF PREPARATION

The appendices were at first fixed in 10 per cent solution formahn, then mordanted in the following fluid:

35 per cent aqueous solution bichromate of potash 92

Formalin (40 per cent formaldehyde) 4

Glacial acetic acid 5

244 HENRY BAYON

The appendices were then imbedded and sectioned in celloidin, stained by Delafield's hematoxylin and counterstained in eosin.

LEVELS AT WHICH STAINED SECTIONS WERE TAKEN

In order to oljtain more reliable data, dissecting-room appendices were not considered. Appendices so diseased as to show disorganization or destruction of their tissues were avoided. Only recently removed appendices gathered from autopsies and abdominal operations at ("harit}- Hospital and Touro Intirmary of this city and preserved in formalin solution were used. The material included twenty-five slides of cross-sectioned a]ipentlices l)orr()wed from the pathological department of Charity Hospital. Each appendix was measured in length and in width and cross-sectioned two or three times from base toward the apex.

The average length, in all cases considered regardless of race or sex, was 9.2 cm. in seventj'-one specimens (table 1) and the average width 6.2 mm. in ninety-eight specimens. The length and width of the 100 aj)])eiidices were not all available. The length was not mentioned in the histories of the twenty-five Charity Hospital slides, and in four of the specimens prepared by myself part of the organ was missing. The width was taken fiom the mounted cross-.sections in all ca.ses except in two, the specimens having been previously opened by the pathologist for inspection.

Tallies 2 and 3 show a sexual difference in favor of the male, giving an average of 9.6 cm. (length) and 6.5 mm. (width) in the male against 8.7 cm. (length) and 6 mm. (width) in the female, tables 4 and o. the racial difference fin the two tables) show an average of 7 cm. (length) and 6.5 mm. (width) in the white and 11.3 cm. (length) and 6 mm. (width) in the negro.

It may well l)e oiijectccl that in tables 2, 3. 4, and 5 the inferences mu.st be unreliable, the nunilier of cases being too restricted. In table 1, however, which deals with the average length of the appendix, regardle.ss of race or sex, the same objection does not prevail. The slight difference in size between the male and female appendix is all that might have been expected, although that,

TABLE 1

Racial and sexual

LENGTH

WIDTH

White male . .

9 cases — ■ 8 cm. 20 cases — 11.3 cm. 37 cases — 6.1 cm.

5 cases — 11 3 cm.

11 cases — 7 mm.

Negro male

28 cases — 6 mm.

White female

37 cases — 6 mm.

71 cases av. 9.2 cm.

98 cases av. 6 2 mm.

TABLE 2 Racial, male

White male. Negro male.

LENGTH

niDTH

9 cases — 8 cm. 20 cases — 11.3 cm.

11 cases — 7 mm. 28 cases — 6 mm.

29 cases av. 9.6 cm.

39 cases av. 6.5 mm.

T^VBLE 3 Racial, female

LENGTH

WIDTH

White female

Negro female

37 cases — 6 1 cm. 5 cases — 11.3 cm.

37 cases — 6 mm. 22 cases — 6 mm.

42 cases av. 8.7 cm.

59 eases av. 6 mm.

TABLE 4 Sexual, white

LENGTH

WIDTH

9 cases — 8 cm. 37 cases — 6.1 cm.

11 cases — 7 mm.

White female

37 cases — 6 ram.

46 cases av. 7 cm.

48 cases av. 6.5 mm.

T^VBLE 5 Sexual, negro

LENGTH

WIDTH

20 cases — 11.3 cm. 5 cases — 11.3 cm.

28 cases — 6 mm.

Negro female

22 cases — 6 mm.

25 cases av. 11.3 cm.

50 eases av. 6 mm.

245

246

HENRY BAYON

together with racial differences, would seciu to otter no sohitit)n to the problem at issne. namely, structural peculiarity bearinjj; an susce|)tihility to inflannnation. The tabulations were simply included as a matter of general interest.

The field which .seemed most promising was the microscopic survey of the transverse sections. This consisted in measuring the thickness of the longitudinal and circular muscular tunics exprcs.sed in terms of microns together with noting the relative amount of h-mphocytes, fat and crypts and the vascularity of each appendix, classifying the specimens into three categories, rich, moderate anil poor, as indicated in table G.

TABI.K 6 Based upon 100 specimens

UUSCDLA

TURE

LTUPBOCrTES

F-AT

CBIPTS

VASCCIABITT

IN UICRON8

S

s

fi

O

s

P

«

e 9

£

•s

1

S

■s

b

•a c

R

1

^

L.

^

O

per

ptr

per

7per

per

5per

per

cent

ernt

cent

X. .M.-31 C.

247 B

3.50 8

16

22

62

23

32

45

19

,5.5

26

64

29

7

X. F. -22 C.

270 4

37.5 3

14

64

T2

41

18

14

36

50

54

27

19

W. .M.— 11 C.

270 4143.5 9

64

18

27

55

18

36

9

65

IS

18

64

W. F. -36 C.

241 2 392 8

47

44

9

59

29

12

62

23

15

16

21

73

A glance at the figures disproves the first impression regarding musculature. It is. therefore, quite evident that inmumitj' from ajjpendicitis in the negro, if such exists, cannot be accounted for by a stronger i)eristaltic wave. Indeed, the measurements show a preponderance of muscular tissue in the white appendix.

The racial and sexual dilTerences in the percentage ot fat conform with the general distribution of fat elsewhere in the sexes and in the two races. The negro as a race carries less fat in the average than the white, and in both races the female carries more than the male.

The dilTerence in the number (tf crypts retained is decidedly in favor of the white appendix. This would seem to indicate ie.ss

RACIAL DIFFERENCES APPENDIX VERMIFORMIS 247

susceptibility to iiifiammation. Hence, the study of structure in this particular feature, far from confirming disease statistics, offers decided opposition and is quite suggestive to the reverse.

The difficulty, however, presented by the crypts is offset very singularly by the findings regarding both the lymphocytes and vascularity. In the white appendices, 64 per cent male and 47 per cent female were found rich in lymphocytes, and 18 per cent male and 16 per cent female were found rich in vascularity. Comparing this with the findings for the negro appendix, 16 per cent male and 14 per cent female were rich in lymphocytes and 64 per cent male and 54 per cent female were found rich in vascularity.

In the cases here examined the ratio in the two races between lymphocytes and vascularity is inverted — the richer in lymphocytes, the poorer the vascularity seems a characteristic of the white appendix, whereas the reverse obtains for the negro appendix, in which the scarcity of lymphocytes corresponds with rich vascularity. From the figures the fact stands out that the white appendix is richly lymphatic and poorly vascular and the negro organ just the reverse.

In the white appendix are found two conditions predisposing to inflammation more especially of the gangrenous type — a rich supi^ly of lymphocytes indicating predisposition to inflannnation and poor vascularity favorable to gangrenous changes.

It may be objected that since the cases were tabulated regardless of health or disease, the prevalence of the appendices rich in lymphocytes might result from inflammatory action. The objection is met by the fact that, although in some cases operation was performed for appendicitis, in a great many other cases operation was performed for disease other than appendicitis, the appendectomy being performed simply as a matter of prudent routine in anticipation of possible future appendical trouble. But even if on that account, the high percentage of organs rich in lymphocytes found in the white cases be considered of negative \alue, the fact remains that these specimens show a low percentage of \-ascularity, and if inflammation alone could suggest increased lymphatic richness, it should also accentuate vascularity, which is (luite contrary to the fiiuling.

248 HENUV HAYON

Racial differences in tlie appendix suggested that corresponding differences might also exist in other diseases of the lymphatic system. Statistical inquiry into the relative number of tonsil and adenoid disease in the two races demonstrated that in 47ol) jiatients admitted into the Charity Hospital during the first three months of 1917, 2258 were negroes and 2501 were whites. In the 22r)S negro cases there were 35 tonsil cases and 8 adenoid cases. In the 2501 white cases there were 95 tonsil cases and 21 adenoid cases.

Table 7 .shows that the numl)er of tonsil ca.ses was more than twice as great in the white than in the negro and that the number of adenoid cases was twice as large in the white.

TABLE 7

22.58 negro patients. 2501 white patients

TONSIL CA8F.S

35 (0.015 per cent) 95 (0.037 per cent)

ADENOID CASES

9 (0.004 per cent) 21 (O.OOS per cent)

In these tonsil and adenoid cases figures may hold out equivocal interpretation : we are well aware that more whites than blacks are prone to l)ecome nervous al)out health conditions and the same suggestion regarding the advisabilitj' of parting with the appendix j)rcvails for tonsils and adenoids. It rests with the specialist whether the organs show sufficient evidence of disease to justify operation and the administration of an anesthetic — alwaj's a grave re.sponsibilit}'. Be that as it may, if each tonsilectomy and adeiioidertomy means disea.sed jialatiiie or pharyngeal tonsil, the unavoidable and iiidisputal)lr inference is that tonsil and adenoitl disease is more prevalent in the white than in the negro.

The .same Ciiarit}' Ilo.spital records for the first three months of 1917 show a total of twenty-three negro cases of aj)pendicitis against eighty-five white cases, ^^■ith due allowance for the doubtful trustworthiness of statistics considered from the standpoint of their face value, it may he safely assumed that when viewed in the liglit of histological findings above submitted, they

RACIAL DIFFERENCES — APPENDIX VERMIFORMIS 249

are at least ((uite suggestive of greater susceptibilit}^ of the white race than the negro to appendicitis.

Differences in the lymphatic system of the white and negro races may also be inferred from the findings of Bean and Baker, which appear in the Journal of Physical Anthropology, vol. 2, no. 1, 1919, under the title of "Some Racial Characteristics of the Spleen Weight in JNIan." 0\'er 1500 white and about the same number of negro spleens are considered, showing a decided difference in weight in favor of the white spleen.

These findings are well correlated to those submitted in the present study and seem to prove that the white race is more subject to lymphocytic stasis than the negro.

SOIMARY

1. The musculature of the white appendix is not weaker. Indeed, it seemed slightly stronger than that of the negro.

2. The female appendix is richer in fat than the male.

3. The white appendix is richer in crj-pts.

4. The white appendix is rich in lymphocj^tes and poor in vascularity and the negro appendix rich in vascularity and poor in lymphocytes.

5. The average size of the appendix is 9.2 cm. in length and ().2 mm. ill width.

6. The white appendix is shorter and wider than the negro appendix.

7. The male appendix is longer and wider than the female apjjendix.

HUMAN PAKASITOLOGY, with xotks ox Bacteuiolocy, Mycology, Lahokatouy Diagnosis, Hematology and Serology, l.y Damos Kivas, B. S. Riol. M.S., M.D., Ph.D., Uiiivcrsily of rciinsvlviinia. Illustrated. 71t> i)agps, W. B. Saunder.s Coini)aiiv. Philadelphia. Pa. 1920.

extracts from preface

A half century ago nieilieine was more an art than a science. The doors of American medical colleges stood wide open to welcome all who came as students, and if they showed a desire to learn, possessed enough elementary eilucatioii to eiiahle tlum to read their text-lmok anil write their examination papers no questions were asked as to their acquaintance with the physical and hiologic sciences.

There was no science of parasitology. Parasites were zoologic curiosities that occasionally intruded into the si)h(>re of medical activity.

Now all has changed. The necessities of commerce have led to such extensive geographic explorations that the entire surface of the earth has been explored and charted. Ethnologic investigators have uncovered the location, life and habits of many formerly unknown peoples.

The general rapid advance of scientific knowledge, especially the progress of physics, chemistry and biology, inevitably reaetetl upon metlicine, stimulating the scientific spirit, demanding research upon its obscure ]jroblems. and re(juiring a new tVpe of student whose jm'paration for medicine must include at least an elementary knowledge of the collateral and fundamental sciences.

The author has for twenty years interested himself in i)arasitology and has had the good fortune to have studied in public health laboratories at home and abroad, an<l to have served on sanitary commissions. Aftrr years of tcacliing he now endeavors to bring together tlie facts of ])arasitology in a form suital)le to the needs of the student and jihysician. The following pages reflect his personal experiences and present the facts of the sul)ject in a fonii sufficiently brief to make it a text-liook — the modern tendency is to be encyclopeilic- and sufficiently full not to omit any imjiortant fact or method.

250

',-"

THE ANATOMICAL RECORD, VOL. 19, NO. 5 OCTOBER, 1920

Resumen por el autor, Carl G. Hartman. Uuiversidad de Texas.

Los fen6nienos del parto en el opossum.

Ell oposici6n a lo que se cree generalmente, el embri6n del opossum, al final del periodo de gestaci6n, que dura diez dias, caniina por sus propios esfuerzos desde el orificio vajiinal hasta la bolsa marsupial, en la que encuentra la mama. La madre no ayuda al embri6n durante su paso desde la vagina a la bolsa, pero le lame para despojarle del liquido cori6nico, cuando sale por la vulva. Lo mismo que en el caso de las especies australianas Perameles y Dasyurus, descrito por Hill, los embriones alcanzan el canal vaginal medio no por los canales vaginales laterales, sino por un tuncl ([ue aparece de novo en el tejido conjuntivo situado entre la uretra y los canales vaginales laterales.

Translation by Joa& F, Xonides Cornell Medical College, New York

AUTHOR S ABSTRACT OF THIS PAPER ISSUED BY THE BIBLIOGRAPHIC SERVICE, SEPTEMBER 13