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Special Articles

"APPENDICITIS" IN YOUNG WOMEN

An Opportunity for Collaborative Clinical Researchin the National Health Service

J. A. H. LEEM.D., B.Sc. Edin., D.P.H.

OF THE SOCIAL MEDICINE RESEARCH UNIT (M.R.C.), LONDON HOSPITAL,LONDON, E.1

* It is understood that copies of these tables are available from theGeneral Register Office for a small fee.

IT is well known that in young women the diagnosis ofappendicitis presents special difficulties, and in many ofthose operated on no convincing evidence of disease isfound (Morrison 1910, Patton 1952, Moir 1954, Samuels-son 1957). An attempt has been made to estimate howcommon such cases are. The development of the NationalHealth Service and of the statistical services associatedwith it has provided fuller information on this kind ofquestion, and also gives new opportunities for investigation.

DATA AND METHODS

Since 1949 the General Register Office and the Ministryof Health have been collecting details, through theirHospital Inpatient Inquiry, of patients discharged fromN.H.S. hospitals. The material for 1956 and 1957 hasrecently been published (G.R.O. 1961). In 1956 the

inquiry covered 67% of the non-teaching hospital beds,and in 1957 it covered 81%; the percentages of theteaching-hospital beds were higher. The hospitals in-cluded formed a very large sample of all those in thecountry. Each hospital contributed details of every tenthdischarge, giving an effectively random sample of its

patients. The data from each of the two years give similarpictures, and they have been amalgamated in the presentstudy. Data from earlier years have also been used wherespecified in the tables.

Besides the age and sex of the patients, the type ofadmission-whether " immediate " or

" other "-wasrecorded. The cases stated by the hospital to be compli-cated by peritonitis are shown separately. Cases where theappendix was removed in the course of surgery for otherconditions have not been included. The data were

originally tabulated in five-year age-groups. As thenumber of cases was large, the G.R.O. kindly re-analysedthe data by single years of age.* In this way a moredetailed picture of the effect of age on the number of casesis obtained.

Fig. I-Number of cases of appendicitis by sex and single years to theage of 40.

The figures are derived from the 18,000 cases of appendicitis at allages reported to the hospital inpatient inquiry, 1956-57, and they arecorrected for variations in the population at risk owing to the"

bulge " of postwar births. (The data of figs. 2 and 3 and table i aresimilar.)

Fig. 2-Number of cases of appendicitis admitted immediately, and member admitted otherwise,by single years to the age of 40.

RESULTS

In males the number of cases treated in hospital forappendicitis is highest at the age of 12 (fig. 1). This peakis followed by a fairly steady decline. In females the totalnumber of cases of hospital-treated " appendicitis "

follows a different course. There is a minor peak at theage of 10, which is found in the data for 1953-55 as well asthose for 1956-57, and which appears to correspond to themale peak at 12. This is followed by a much larger peak at17. By the mid-20s the number of cases in females isagain similar to that in males of the same age.The great majority of the male cases of appendicitis are

admitted " immediately ". The male cases not admittedin this way are most common at the age of 12, and numbersthen decline slowly (fig. 2). In contrast, the non-

" immediate " cases in femalesform a greater proportion of thetotal and are most common

between the ages of 14 and 26.As a result, the extra cases called"

appendicitis " in young womenabove what might be expectedare made up of " immediate "and non-" immediate " cases inabout equal numbers.

In both males and females thenumber of cases of appendicitisreported as being complicated byperitonitis is high in childhoodand declines to a minimum inthe late 20s and early 30s (table i).In the general population death-rate from appendicitis follows a

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TABLE I-NUMBER OF CASES OF APPEKDICTTIS WITH PERITONITIS BY

SEX AND AGE

* Hationai Hospital Inpatient Inquiry 1956—57.

similar trend (table 11). Thus neither of these indices ofinflammation of the vermiform appendix shows anyincrease or excess in young women.

Data have been collected by the Hospital InpatientInquiry since 1949. Each year the number of hospitalscontributing has increased. Because of this change in thesize of the sample, simple comparisons from year to yearof the numbers of cases reported of a particular conditioncannot readily be made. But the excess of female overmale cases in the ten-year age-group 15-24 has remained

remarkably constant, suggesting that there is no tendencyfor this rate of hospital treatment for " appendicitis " infemales to diminish (table III). Further, it is similar in themost recent data to what it was in the early 1930s (Youngand Russell 1939).

All the cases being considered had " appendicitis " astheir principal diagnosis when they left hospital. In the

age-group 15-24 in 1956 (the only year for which figures

TABLE U-DEATH-RATES PER MILLION PER ANNUM FROM APPENDICITIS

BY SEX AND AGE

England and Wales, 1954-58.

TABLE III-RATIO OF FEMALE TO MALE CASES OF APPENDICITIS AT AGE

15-24

Young and Russell (1939). t National Hospital Inpatient Inquiry, 1949-57.

are available) 94% of the female cases with this diagnosiswere treated by appendicectomy, and 93% of the male. Theduration of stay was similar in males and females, theaverage being about nine days.The marital status of the female cases was recorded,

and it is possible to calculate approximate age-specifichospital admission-rates for " appendicitis

" for themarried and the single (table iv). The rate in the single isgreater than in the married, but in both married and singleit declines rapidly in the 20s. No information on fertilitywas collected. +

DISCUSSION

The epidemiological method used here can contributein various ways to the solution of a problem. It can helpto clarify and to define its extent, and it can put individualclinical experience in a community perspective. It canremind doctors of problems that have grown familiar, andit may be able to point the way to their solution or at leastto ways in which they can be tackled (Morris 1957).The excess in the number of reported female cases of

appendicitis between the ages of 14 and 26 over whatmight reasonably be expected is at least 7500 in N.H.S.

t The fertility of women dy’il’1g of appendicitis is similar to that ofwomen dying from all causes (G.R.O. 1958;.

hospitals each year in England and Wales—enough to fullyoccupy a 200-bed hospital. Since the beginning of theN.H.S. some 100,000 of these extra cases called "appen-dicitis " have been operated on in England and Wales.The chance that a girl of 17 will be operated on forappendicitis is twice what it is for a girl of 13; for males ofthe same ages the chances are approximately the same.There is no evidence that the number of these cases is

declining as the years pass (table ill). Thus the introduc-tion of sulphonamides and antibiotics, and all the otherdevelopments in therapeutics and diagnosis, have notmaterially affected the problem. The excess of thesecases is as great in the teaching as in the non-teaching

TABLE Iv-ESTIMATED HOSPITAL INPATIENT DISCHARGE-RATE * PER

1000 PER ANNUM FOR APPENDICITIS IN SINGLE AND MARRIED

WOMEN BY AGE

Calculated by scaling up the reported cases (using the factors given by theG.R.O. for teaching and non-teaching hospitals), and expressing theseestimated numbers for the country as a whole as rates in the populationat risk. England and Wales, 1956-57.

hospitals (fig. 3). A similar excess of " appendicitis " inyoung women is found in other British data (e.g., WarOffice 1948, Ministry of Pensions and National Insurance1958, G.R.O. 1959, Air Ministry 1961). It is also found inAmerican series (e.g., Eisele et al. 1956, Collins et al. 1956,National Health Survey, United States 1959).These cases have been discharged with a diagnosis of

" appendicitis " after undergoing appendicectomy, but noinformation is available about the histological findings.There seems to be no British series large enough to bedivided into age and sex groups, in which the criterion forinclusion has been histological evidence of disease; but intwo large American series where this was done no excessin young women was found (Green and Watkins 1946,Eisele et al. 1956). This is in agreement with data fromthe two indices of real appendicitis that we have for

England and Wales-the cases complicated by peritonitis,and the fatal cases (tables i and II).These extra cases labelled " appendicitis

" that occur in

Fit. 3—Ntunbor of cases of all typa of hospitals, by ia fcm.a1-treated in teaching and non-teaching hospitals, by 2-year a gr-groups to the age of 40.

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young women are thus probably not due to inflammationof the vermiform appendix as ordinarily understood.There is no adequate evidence of the value of appendicec-tomy in them (cf. Querido 1959), and no reason to believethat real inflammation of the appendix is particularlylikely to occur in young women (cf. Boyce 1949, Bailey andLove 1959). On the other hand, there are a variety ofgynxcological syndromes such as

" dysmenorrhoea"(Drillien 1946, Lowe and Ferguson 1951) and disturbancesof ovulation (McSweeny and Fallon 1950, Collett et al.1954) which are especially common in young women.These extra cases of " appendicitis " decline rapidly inthe early 20s, at a time when the marriage-rate is high.The data reported in this paper show that the incidence ofthese cases is lower in married than in single women of thesame age (table iv), but they also suggest that the incidencedeclines in both the married and the single during the 20s.The data, therefore, do not support the suggestion thatthe disappearance of these cases of " appendicitis

" in themid-20s is due to marriage.The persistence of these cases emphasises the difficulty

of the practical problems which they present. These

problems are diverse-for some cases present as emergen-cies while others run a chronic course. The moreacademic question of the nature of the disease or diseasesfrom which these patients are suffering, and the practicalone of management, are linked. Progress with eitherwould help in the solution of both.One difficulty is numbers. Although these cases of

" appendicitis " in young women are common, and thenumber treated in the country as a whole is large, on theaverage each consultant general surgeon will only beresponsible for the care of about 10 cases a year. Whilethere must be large variation around this figure, theopportunities for an individual surgeon or hospital tocollect a substantial series of cases are clearly small.

Perhaps for this reason, there appears to be no definitivedescription of the clinical features of appendicitis in youngwomen which contrasts the features found in cases thatwere confirmed histologically with those that were not,and compares both with the findings in males of the sameage.The regional organisation of the N.H.S. seems well

adapted to tackle this kind of study. It can be estimatedthat each year in the Welsh region, which is one of thesmaller ones in terms of population but one for which thenecessary figures happen to be available (G.R.O. 1959),500 more cases of " appendicitis " are treated each year infemales aged 15-24 than in males of the same age. If allcases diagnosed as

" appendicitis " and aged between15 and 24 in all the hospitals of a region, and the associatedteaching hospital, were reported in uniform detail to aregional committee, the clinical findings on sufficient casescould be analysed. It would be important to include theteaching hospital, because these problems appear to be asdifficult in these hospitals with their greater resources asthey are in the non-teaching. At the same time thehistological reporting on the tissues could be done" blind " without reference to the clinical features. Sucha study should make it possible’to establish, for example,which pre-operation features were associated withunequivocal inflammation of the appendix; and whetherthere were any associations between clinical features andless definite histological changes. Further, it would also beworth comparing the female cases where the patient hadbeen seen by a gynaecologist before operation with those

where she had not.+ Perhaps in some hospitals all femalepatients suspected to be suffering from appendicitis couldbe seen routinely by a surgeon and a gynaecologist.The subsequent history of a representative sampleof patients operated on for " appendicitis

" might also bestudied.

Are these problems worth solving ? There is no evidencethat appendicectomy helps these patients. The blockingof beds and the diversion of surgical facilities is not small.The use of this operation and diagnosis may well bedelaying a better understanding of the disorders in

question.SUMMARY

The difficulties of the diagnosis of appendicitis in youngwomen are well known. An attempt has been made todiscover the number who undergo appendicectomy butare probably not suffering from inflammation of theappendix.

In National Health Service hospitals of England andWales this number is 7000-8000 each year; since the startof the service there have probably been about 100,000 suchoperations. The number of girls of 17 discharged fromhospital with the diagnosis of appendicitis is twice whatmight be expected. On the other hand, young womenshow no excess of appendicitis complicated by peritonitis,or of fatal appendicitis.These cases are as common in the teaching as in the

non-teaching hospitals, and their number is not declining.A collaborative study of the clinical and pathological

features of all cases described as " appendicitis " in youngpeople, in one or more hospital regions, might throw lighton this disease.

The General Register Office of England and Wales kindly madethe special tabulations of the data from the National HospitalInpatient Inquiry which they carry out jointly with the Ministry ofHealth. I am grateful to Mr. R. A. Brews, F.R.C.O.G., and Prof.I. Doniach, M.D., of the London Hospital, for helpful criticism, andto Prof. W. T. Irvine, F.R.C.S., who was also at the London Hospitalwhen this work was done. I have had many useful discussions of thisstudy with Prof. J. N. Morris and my colleagues of the SocialMedicine Research Unit.

REFERENCES

Air Ministry (1961) Report on the Health of the Royal Air Force andWomen’s Services of the Royal Air Force, 1959; pp. 27 and 55. London:Air Ministry.

Bailey, H., Love, M. (1959) A Short Practice of Surgery; p. 589. London.Boyce, F. F. (1949) Acute Appendicitis and its Complications; p. 43.

New York.Collett, M. E., Westenberger, G. E., Fiske, V. M. (1954) Fertil. & Steril.

5, 437.Collins, S. D., Lehmann, J. L., Trantham, K. S. (1956) Surgical Experience

in Selected Areas of the United States. Public health monograph no. 38,p. 36. Washington, D.C.

Drillien, C. M. (1946) J. Obstet. Gynœc. Brit. Emp. 53, 228.Eisele, C. W., Slee, V. N., Hoffman, R. G. (1956) Ann. intern. Med. 144, 1.General Register Office (1958) Unpublished.

— (1959) Registrar General’s Statistical Review of England and Wales,1955. Supplement on Hospital Inpatient Statistics; p. 50. H.M.Stationery Office.

— and Ministry of Health (1961) Report on Hospital inpatient Inquiryfor the Two Years 1956-57. H.M. Stationery Office.

Green, H. W., Watkins, R. M. (1946) Surg. Gynœc. Obstet. 83, 613.Lowe, C. R., Ferguson, R. L. (1951) Brit. J. soc. Med. 5, 193.McSweeny, D. J., Fallon, R. J. (1950) Amer. J. Obstet. Gynec. 59, 419.Ministry of Pensions and National Insurance (1958) Digest of Statistics

Analysing Certifications of Incapacity 1955-56; p. 48. London:Ministry of Pensions.

Moir, J. C. (1954) Brit. med. J. ii, 1415.Morris, J. N. (1957) Uses of Epidemiology. Edinburgh.Morison, R. (1910) Med. Annu. p. 152.National Health Survey, United States (1959) Unpublished.Patton, G. D. (1952) Amer. J. Surg. 84, 215.Querido, A. (1959) Brit. J. prev. Soc. Med. 13, 33.Samuelsson, S. (1957) Acta. Obstet. Gynec. scand. 36, suppl. 9.War Office (1948) Statistical Report on the Health of the Army 194-45;

p. 249. H.M. Stationery Office.Young, M., Russell, W. T. (1939) Appendicitis, a Statistical Study. Spec.

Rep. Ser. med. Res. Coun., London. no. 233; p. 38. H.M. StationeryOffice.

No record was made of the proportion of patients who were seenin consultation with a gynaecologist. There is no reason tobelieve that many were operated on by gynecologists.