Talk:Paper - Congenital absence of the appendix of the caecum (1915)

CONGENITAL ABSENCE OF THE APPENDIX OF THE CAICUM. By ReainaLp J. GLADSTONE, M.D. Aberd., F.R.C.S. Eng., F.R.S. Edin., Lecturer and Demonstrator of Anatomy, University of London, King’s College.

CoNGENITAL absence of the cecal appendix is an extremely rare abnormality. R. J. Berry, writing in the Anatomischer Anzeiger in 1895 (1), after having reviewed the literature on the anatomy of the appendix up to that date, and having reported 100 cases of his own, states that “some authors have described total absence of the appendix: I do not, however, believe that the appendix is ever absent except as the result of a previous excision.” Later, in 1907 (2), the same authority refers to a specimen belonging to Professor Fawcett, and writes: “The fact remains that it is the only case on record of congenital absence of the appendix vermiformis.”

In the systematic examination of 1852 subjects, in which special attention was given to the anatomy of the cecum and appendix, there was only one case in which the appendix was absent, namely, Faweett’s.

Number of Absence Cases examined. of Appendix. Monks and Blake (3) . . 641 0 Fawcett and Blatchford (5). . 350 1 Ribbert . . . . . . 161 0 Berry (2) . . . . . 100 0 Treves (14). . . . . 100 0 1352 1

Other undoubted cases of congenital absence of the appendix have, however, been recorded by Zuckerkandl, Bryant, Huntington, Meckel, Robinson, and others. I have myself seen three specimens. Two of these are in the Museum of the Royal College of Surgeons, England: Specimen . 549 of the Teratological Series, described in the catalogue as “ Part of the ileum and cecum of a human fcetus in which the appendix is absent and the cecum is very short,” presented by Sir J. Bland Sutton; and Specimen 549-11, presented last year by Dr E. A. Chill. In this specimen also the cecum was rounded and very short. It occurred in a new-born child, in which there was also an epi-cephalocele. The third specimen (fig. 1), Congenital Absence of the Appendix of the Caecum 415

which forms the subject of this communication, was discovered in the Anatomy Department at King’s College, University of London. It occurred in a woman who was certified to have died, aged sixty-three, from arterial sclerosis and heart failure. There was no scar in the abdominal wall, nor were there any signs of inflammation in the region of the cecum. The cacum was in the usual situation, and was normal in

Fic. 1.—A symmetrical type of cecum, with absence of the appendix.

size and form. It was completely covered by peritoneum. The “teniz coli” converged to a point, on the medial and posterior aspect of the cecum, 1} inches below the ileo-cxcal junction. No trace of an appendix was, however, visible from the outside. On examining the mucous membrane lining the interior of the cacum, a small patch of what appeared to be adenoid tissue was found opposite the point of convergence of the three teeniz coli, and in the position in which one would expect to find the orifice of the appendix.

The distal end or fundus of the cecum was formed by a sacculation 416 Dr Reginald J. Gladstone

which lay to the right of and below the point previously mentioned to which the longitudinal muscular bands converged. This case therefore differs from those described by Huntington; in one of which the cecum was round and globular and the muscular bands converged to the lowest point of the pouch, and a second in which the cecum turned upward and to the left, and ended in a sharp point, to which several lobes of epiploic fat were attached.

The very rare occurrence of total absence of the appendix is a matter of some surprise. On considering the subject from the standpoint of comparative anatomy, one would expect that an organ which is absent in such a large number of orders and species of vertebrate animals, and only present in higher types (anthropoid apes, certain. rodents, and the wombat), would frequently be absent in man.

Vestigial structures are usually, though not always, variable in the extent of their development, and are frequently found to be absent altogether. This is especially the case when the structure or organ has no apparent functional importance. The fact that although the cecal appendix varies very considerably in its length, form, and disposition, it is so rarely absent, supports the views put forward by Berry, Keith, and others regarding its functional importance.

From the standpoint of ontogeny, one would also expect congenital absence of the cecum and appendix to be a much more frequent occurrence than it is. In a human embryo of 7:5-mm. length (Harvard College) the cecal diverticulum is recognisable as a slight swelling on the distal limb of the intestinal loop. In an embryo of 17 mm. (Mall) this bulging is more pronounced and forms a rounded swelling, such as is seen in Specimen 629, R.C.S. Eng. In a later stage (in an embryo also 17 mm. in length) it becomes conical. Between 40 and 50 mm. a narrower distal part which will become the appendix can be distinguished from a wider proximal part which will become the cecum. It is not, however, until after birth that a sudden diminution in the calibre of the gut marks off the root of the appendix from the cecum, which is at this stage symmetrical in form, the appendix coming off from its lowest point. The asymmetrical form is not developed until a few years after birth. ,

Arrest of development may occur at any of these stages and give rise to:—

“Absence of the cecum and appendix” (Robinson); “ Rudimentary cecum without appendix” (Sutton, Chill); “A cecum having a blunt conical form without appendix” (Huntington); “A caecum having a rounded symmetrical form, with the longitudinal muscular bands converging towards its apex, but without appendix” (Huntington); “ Asymmetrical form of cecum without appendix” (Author). Congenital Absence of the Appendix of the Cacum 417

REFERENCES TO LITERATURE.

1) Berry, R. J. A., Anat. Anz., Jahrg. x., 1895.

) ) Berry, R. J. A., Lntercolonial Med. J. of Australasia, vol. xii., 1907, p. 305. ) Brake, see Monks.

) BiatcHForD, see FAWCETT.

) Fawcerr and Biarcurorp, J. Anat. Physiol., vol. xxxiv.

(6) Keiru, A., Proc. Anat. Soc., Nov. 1903, p. 7.

(7) Huntinetox, The Anatomy of the Human Peritoneum and Abdominal Cavity, 1903.

(8) Hurpon, see KELLY. (9) KeipeL and Mati, Manual of Human Embryology. (10) Keniy, H. A., and Hurpon, E., 7he Vermitorm Appendix and its Diseases. (11) Monks and Bakes, Boston Medical and Surgical J., Nov. 1902. (12) Quaty, R., vol iii. part iv. (13) Ransonorr, J. Amer. Med. Ass., 1888. (14) Treves, F., Zntestinal Canal in Man, London, 1885. (15) ZucKERKANDL, E., Anat. Hefte, Bd. 4, 1894.

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