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版权信息
书名：祖荫下：传统中国的亲属关系、人格和社会流动

作者：许烺光

译者：王燕彬

出版社：九州出版社

出版时间：2023-09-15

ISBN：9787522518848

品牌方：后浪出版咨询（北京）有限责任公司
献给拉尔夫·林顿(Ralph Linton)
 此书的完成和出版得益于维京基金会(Viking Fund, Inc.)的资
助，该基金会由温纳—格伦(A. L. Wenner-Gren)创建和捐资，致力于
推动科学、教育以及慈善事业。维京基金会并非本书的作者或出版
方，因此，基金会虽然提供了支持，但不对此书的任何观点和内容负
责。
前言
在本书中，我致力于三件事。首先，我描绘了中国西南的一个小
型半农社区(a small semi-rural community)，分析了它的文化，尤
其是其家庭模式和宗教生活。其次，我探讨了这一文化在构成此社区
的诸多个体的人格形成中所起的作用。最后，在描述完该地的若干人
格结构(personality configuration)之后，我指出它们适用于解释过
去和现在的整个中国社会。

关于中国文化的统一性(unity)，仍有待进一步研究，我相信日后
的工作将做到此点。当下我只能说，我确信自己所研究的社区的基本
社会结构(essential social structure)也是整个中国的典型结构。这不
完全是一个假设，因为有证据表明（在此我暂不赘述以免增加读者负
担）：中国文化的统一性，与中国文化的多样性这个概念一样，在作
为前提条件时至少具有同等合理性。

本书所依据的田野材料收集于1941年7月至1942年6月，以及
1943年7月至9月。当时我任教于昆明的国立云南大学。这一时期的田
野工作极其困难。通货膨胀导致我需要不断想方设法解决经费问题。
我到西镇(West Town)时，当地物价约为1937年物价的15倍。在我的
第二次访期将尽之时，物价已越200倍之巨。此外，西镇虽从未落入
敌手，但仍不可避免地受战乱波及。在我的整个调查期间，政府一直
在强制征兵，多数家户由于不了解征兵的目的，试图逃脱兵役。在此
情况下，任何外来人，尤其是四处打听的人，便成了他们怀疑的对
象。并且，我第二次来时，缅甸已经陷落，这让战火空前迫近西镇，
局势愈发紧张。

在缪云台先生和已故的袁丕济博士领导的云南省经济委员会的慷
慨援助下，通货膨胀导致的资金困境得到了极大改善。由于我在避难
至此地的教会学校里担任临时教师，这一定程度上改善了我难以获得
信任进而建立融洽关系的困难处境。大多西镇人显然认为，我虽然对
当地宗教习俗仍有成见，但至少不是政府派来打探消息以抓捕更多壮
丁的密探。

就我的研究而言，通货膨胀其实并不完全是坏事，因为它把学者
的生活水平降到了与劳动者、小商贩持平的境地（如果不是更低的
话），从而消弭了人们对于学者的敬畏之情以及面对知识分子的传统
自卑感。事实上，那时学者们常常是人们的同情对象，而他们亦当得
起这同情。因此，我在田野调查过程中获得了许多机会，得以与那些
此前几乎不会信任我的人建立紧密关系。

尽管如此，我无意声称西镇人总把我当作团体中的一员。我采用
的都是常见的人类学研究方法：观察，倾听，参加各种我能接触到的
宴会、典礼、仪式和家庭聚会，并考察人们互相矛盾的说法。虽然人
们以同情之心待我，但我始终是外来人，尽管就体质特征而言，我与
社区中的其他人着实无异。
 我要感谢许多人，没有他们的帮助，此书决计无法完成；我也要
对斧正此书的人致以谢意，没有他们，此书也无法精益求精。费孝通
博士是我在国立云南大学的同事，本书标题即得益于他的指教。同单
位的同事史国衡先生和瞿同祖教授，也曾就书中材料和我进行了多番
极富成果的讨论。史先生生长于湖北乡村，对观我的发现和他家乡社
区的风俗，这种比较本身就极具启发性。感谢拉尔夫·林顿博士友好的
关切和对于手稿的宝贵批评，本书的出版离不开他的推荐。塔尔科特·
帕森斯博士(Dr. Talcott Parsons)、克莱德·克拉克洪博士(Dr. Clyde
Kluckhohn)和罗伯特·雷德菲尔德博士(Dr. Robert Redfield)阅读了本
书初稿，他们的建议和批评令我受益匪浅。我要感谢维京基金会，其
资助使我得以完成大部分书稿，并使手稿出版成为可能。感谢维京基
金会的研究部主管保罗·费约什博士(Dr. Paul Fejos)对我的鼓励，以及
对 我 初 到 异 国 所 遇 困 难 的 理 解 。 感 谢 魏 特 夫 博 士 (Dr. K. A.
Wittfogel)，我们就中国社会的结构和功能进行了多次讨论。纽约州
雪城的保罗·汉森(Paul T. Henson)少校和我在天津的哥哥许克光先生
在我的田野工作和写作期间慷慨地给予我经济支持，康奈尔大学研究
生院的沃茨·坎宁安(G. Watts Cunningham)院长提供了一项资助“地
方志”(District History)分析的研究经费。现正于康奈尔大学攻读研
究生学位的乔伊特·赵(Jowitt Chao)和吴志伟(Chihwei Wu)两位先
生，在从“地方志”摘录必要资料的艰巨任务中提供了极大帮助。我
还要感谢瞿同祖教授的夫人帮助书写了许多图表中的汉字，劳雷尔·瓦
格纳小姐(Miss Laurel Wagner)对图表的贡献，艾达·琳恩小姐(Miss
Ida Lyn)和尤金妮亚·波特小姐(Miss Eugenia Porter)在编辑手稿和出
版 此 书 时 的 卓 越 工 作 。 最 后 ， 我 要 感 谢 我 的 妻 子 许 董 一 男 (Vera
Hsu)，感谢她一直以来对我的莫大帮助。

许烺光

西北大学

美国伊利诺伊州 埃文斯顿

1947年11月
第一章 绪论
我十四岁时，曾听父亲与长我二十岁的长兄讨论熟识人家的家业
兴衰及其境遇。兄长总结道：“资财是公家(the nation)之利，私家
(every family)只是暂时拥有，实则周转不息。”我已经记不得父亲的
回答，但从那时起，我意识到家族的命运沉浮，不仅在我熟悉的周遭
世界如此，在我几无所知的其他社区亦如此。

颇有意思的是，杨懋春博士在描绘自己于斯长成并有亲身感知的
华北农村老家时，有如下观察结果：

我们村没有一家能保有地产规模不变超过三代四代。一个家庭往
往辛勤劳作、省吃俭用，直至能买地置业。第二代承袭此道，继续购
买田产，使得家族兴旺富庶。而第三代便开始耽于享乐，入少出多，
他们不再添置新的土地，渐渐地还开始变卖祖产。到第四代，土地卖
得更多直到家族一贫如洗。如此循环甚至无须百年即可完成。这挥霍
无度的一代过世之后，他们的孩子再次开始积攒财富。这些人出身穷
苦，深知拮据为何物，他们认识到努力劳作和勤俭节约对于恢复家族
财运之必要。此时原来的大家族已经不复存在，取而代之的是若干贫
困的小家庭。其中有些小家庭开始购置土地。于是同样的循环再次开
始。

就资源和人口的比率而言，在给定技术条件下，这一观察结果缺
乏可信度，几近于天真。因为人口过剩在中国是显而易见的事实。即
使所有可耕种土地在农民中均分，人均土地占有量也不足半英亩 。
仅靠“努力劳作”和“勤俭节约”，恐怕难以使家族繁荣兴盛。但
当我们考虑到这种不利境况对所有家庭来说都是同样的，我们就不难
肯定上述有关家族变迁的观察。

并且，家运兴衰不仅体现在农民身上。这在帝国的显赫家族那里
也十分显著。有些家族在几代人内其兴也勃焉，但其中大部分其亡也
忽焉，几代之内就跌为寻常百姓家。许多家族都是在两代人内起起落
落。

为了寻找文献证据，我查阅了一些典籍，包括《历代人物年里碑
传综表》 和《清代名人传略》 。第一本书包含超过12000项条
目，我比较了其中所有同一姓氏的人物的籍贯。如果两个姓氏相同且
籍贯相同的人，年龄差在15—60岁之间，我便假定两人存在血缘关系
——可能是父子或祖孙关系。结果表明，符合此标准的人数少得惊
人。

第二本书提供了在一个王朝（清朝）内约700人的传记，以及关
于他们的出身、生平和功业等详细材料。对这些数据的研究表明，在
任何一个家族中，尤其是在直系亲属之间，才智，特别是政治声望很
少能持续两代以上。父子二人都杰出到足以被列为两个单独条目的情
况就更为稀少了。

当然，有人可能会提出反驳，认为这两本书仅仅记录了地位尊崇
之人，而忽视了地位低微的群体。我们可以通过对地方志中所载传记
的研究来回应这一反驳，该研究详情载于附录四。

尽管这些记载有其局限性，我们却不能不为它们揭示的事实所震
惊，尤其是考虑到它们所处的文化——时至今日，在这种文化中，对
于多数天资聪颖且追求功业的人而言，人生唯一的重要目标仍是在官
僚体制中取得上位。当我们意识到政治地位并不取决于人地比例
(man-land ratio)，而是强烈地依赖于影响力，尤其是家族影响力
时，这些史录所揭示的事实就更为惊人了。正如古谚所云，“一人得
道，鸡犬升天”。

如此，我们便面临一个悖论。一方面，社会和政治爬升机制的内
在倾向促使显要的家族延续荣光直至无限，特别是在直系亲属之间。
另一方面，这些显赫的家族实际上往往在较短的时间内便衰落了。

为什么家族会兴衰沉浮？我仔细地分析了其中一些家族，发现那
些导致家族兴盛或衰落的成员的行为表现形成了鲜明的对比。兴家者
往往谨慎、理性、节俭、勤劳和诚恳，而败家者则多虚荣、冲动、奢
侈、散漫和傲慢。随后，我研究了朝代的兴衰，查阅了一些旨在阐述
所谓中国历史之循环的文学作品。著名历史小说《三国演义》的作者
在其杰作的开篇便展现了一种宿命论式的洞察：“话说天下大势，分
久 必 合 ， 合 久 必 分 。 ”(The conditions under heaven are such
that, after a long disunity, there will be unity; after a long unity,
there will be disunity.)
 采用社会科学方法的历史学家在这一主题上基本分为两个流派。
一派以魏特夫博士为主，认为中国社会由三部分组成：(1)国家或统治
阶级；(2)官僚集团，以及与其共生的阶层；(3)百姓或农民。这派观点
是，随着时间推移，社会的第二部分会倾向于牺牲其他两部分来为自
己谋利，从而导致普遍危机和王朝覆亡。用魏特夫博士自己的话来
说：

由此产生了一个经济—政治的恶性循环：新型私有财富累积，官
员、“乡绅”、巨贾私有田产累积，田赋减少，国力疲弱，耕地危
机，内部危机，外部危机（入侵），国家危机。尽管这一恶性循环会
因为“朝代”兴替而得到周期性缓解，但是从未被真正克服。

另一派学者的观点则是基于人口过剩这一相对较为明显的事实，
提出时间更早，故而得到了更广泛的认同。他们的结论是，天下承平
日久，人口增加，但资源，即土地和技术，却基本保持不变。当人口
过剩超过临界点，动乱时期随之而来，饥荒、洪涝、瘟疫、内战和无
处不在的匪患又使动乱加重。这导致人口大幅度减少，使得国家在新
的朝代重新获得一段和平时期。 有一位作者谈到，他越是研究中国
社会，就越是信服著名的马尔萨斯人口法则。

无可否认，这两种进路各有其道理，但若按照我的思路则有一个
新的要素。我仔细考察了统治者及其官僚机构的情况，发现王朝的开
创之君与其先辈面对自身问题时通常展现出智慧和洞察，在治国理政
上也极其勤勉，兢兢业业。而失国之君及其前任则显然缺乏对于问题
的良好判断力和理解力，他们要么荒淫残暴，要么软弱无能。前者通
常有一班贤臣良将；后者则主要依赖宦官后宫，对诤臣却闭塞天听，
甚至残酷杀害。在这样的统治下，纵使百姓穷困潦倒，哀鸿遍野，皇
室及官僚在花销上仍有增无减；统治者和他的宠臣或是没能意识到形
势之严峻，或是故意置之不顾。

因此，在王朝倾颓之际，不仅可以看到官僚干扰田赋以及人口过
剩等问题，统治者及其臣子的羸弱也同样显而易见。后者所起的作用
实在不能小觑。

从这个角度来看，小型社区中普通家族的盛衰、庙堂上的宦海沉
浮，乃至帝王统治的兴亡，都呈现出共同的特征。兴盛的家族群体通
常由拥有一系列人格特质的个体组成，而衰落的家族群体则往往由具
有不同的另一系列人格特质的个体构成。

为什么组成没落家庭的多是软弱人格，而兴旺家庭的成员则具有
坚强特质？就统治阶级而言，继承人和其余年轻子嗣过早地接触后宫
和宦官，至少部分造成了其软弱无能。但在普通家族中并没有这样现
成的答案。这个问题困扰我多年。不久前我意识到，在中国一些地
区，富裕之家和贫困之家在社会行为(social behavior)上存有差异。
富贵人家和书香门第往往比穷苦家族更加执着于社会所认同的大家族
理想；这一点明确地解释了富人中大家族作为一个整体和穷人中家庭
作为一个整体，两者之间的鲜明对比。

以此差异为出发点，我开始对西镇的文化进行分析。我们或许可
以在这里找到长期未决的问题的答案——与其说是富人和穷人社会行
为之间的差异，不如说是同种社会行为因为经济和身份的不同而导致
的结果上的差异。此处所言的社会行为以“祖荫”为核心。

在西镇文化中，祖荫对个体人格最重要的影响因素有两点：权威
和竞争。前者包含了父子一体(father-son identification)和大家族理
想；后者就以下三项或其中一项进行：(1)共同祖先的荣耀，(2)宗族内
某特定支系的荣耀，(3)祖先后代中最受青睐或最显赫的地位。

父子一体和大家族理想互为支撑。二者共同造就的社会体系
(social system)，彻底剥夺了年轻一代全部的独立意识，同时又使他
们可以分享源于近祖或者远祖的财富或荣耀。这些因素也为某种教育
奠定了基础，这种教育依赖于过去，旨在以长者的形象塑造年轻人，
并鼓励这里的年轻人比欧美的青年更早地进入成人世界。

这种世代间的父子一体及教育过程的必然结果是，富人的儿子像
他的父辈一样富有，穷人的儿子和他的父辈一样贫穷。富人的儿子不
仅继承父亲的财富，还享有他的权力和威望。穷人的儿子除了承袭父
辈的贫困，还熏染了他的卑微或低贱。和父亲一样，穷人的儿子必须
辛苦劳作以求所需。他们不得不和父辈们一样为生存而挣扎。富人的
儿子处境截然不同，他们的父辈可能通过劳作博取了今日的地位，但
因为害怕有损父母颜面，他们自己不能通过劳作获得所需。对富人而
言，儿子不用工作是他们社会身份至关重要的一部分。在这种情况
下，年轻一辈没有任何表达自我的有效途径。现在，他们和自己的父
亲一样，想要什么都唾手可得。事实上，无论他们自己是否欲求，财
富、权力和声望都会纷沓而至。
 这些差异在影响个体人格的第二个要素上最为显著，这种文化所
定义的竞争不过与权威一脉相承，并进一步扩大了其影响。

无论贫富，西镇人的竞争都十分激烈。但穷人仅是为了生存而竞
争，富人则远不止于此，他们是为了权力和声望而争斗。这就导致了
两点差异。第一点，穷人为谋生计疲于奔命，几乎无暇顾及旁的事，
因而祖先意识薄弱。至少，他们不以告诉祖先自己的现状为荣。富人
生活优裕，可以轻易过上自身所欲求的生活。他们过得快活，主要的
快活之事或是光宗耀祖，或是让子女在亲族中出类拔萃，或两者兼而
有之。

第二点差异其实已经包含在第一点中。他们不仅在祖宗面前竞争
眷顾，也在家庭内部竞争。贫穷家庭的年轻一辈不仅对远祖毫不关
心，也没有动力去争取父辈的认可。穷困的长辈亦没有任何物质财富
可以留给年轻人，而富裕的父亲则可以用纯粹物质的方式来表达自己
的满意和不满。

因此，虽然父子一体同样存在于贫富之家，但经济地位的殊异导
致富裕的年轻人和贫穷的年轻人形成两种类型的人格：前者高度依赖
长辈和传统权威，后者高度独立于长辈和传统权威。终其一生，穷人
的孩子必食力而得，富人的孩子则坐享其成。

这一现象不仅存在于小社区的人们中，对于大地方的居民亦是如
此；不仅平民百姓如此，达官显贵也别无二致。
研究方法
在以下各章节中，我试图描述和分析西镇中此类 人格类型和其
他人格类型的文化背景。在此之前，需要先简述一下研究方法。“人
格”一词意指“个体的心理过程和状态的有组织集合” 。这一定义
强调个体的独特性(what is unique)。换言之，该集合的特征可为若
干个体所分有。在此情况下，便产生了“人格结构”，如果这种人格
结构的要素在一种文化中几乎普遍存在，我们就称之为“基本人格结
构”。如果一种人格结构被社会特定身份群体中的大多数人所分有，
即为“身份人格结构”。 身份人格结构是基本人格结构的某种变
体，二者并非互相对立。

然而，要明确和系统化不同文化背景下不同类型的人格结构的内
涵，并将其纳入某种分类秩序中，是极其困难的。非但难以获得清晰
图景，反而还会发现彼此共识寥寥。建立普遍有效、具有意义的范畴
也殊为不易。克雷奇默、尼采、荣格、斯普朗格、弗洛伊德等人都曾
做出杰出贡献。 但当我试图将其中一些体系运用到所考察的文化当
中时，我发现要么是许多事实被遗漏在外，要么就是以上范畴对于手
头问题贡献无多。

我毫不怀疑自己失败的主要原因是我对心理学所知甚少，事实
上，我在田野时也没有与心理学家或精神分析学家合作。
 认识到自身局限后，我便采取另一种研究思路。我不再采用固定
的心理学范畴及其固定的内涵来研究文化，而是以人们的行为活动为
指南。我以日常用语(common-sense denominator)代替心理分析
术语。因此，我用的范畴和术语虽不精确，但对于我所要研究的文化
更富意义。我的分析和结论也许无法触及最深层的意识，但至少提供
了一个合适的视角来观察此文化的所有相关事实。

这一研究路径与阿布拉拇·卡丁纳博士(Dr. Abram Kardiner) 的

方法有相似之处，它们都在类型特征的描述和解释上具有相当的灵活
性。但我们又有几个方面的不同。第一，卡丁纳的著作采用弗洛伊德
术语，而我当下的研究则没有；第二，虽然卡丁纳意识到任何一种文
化的全部内容都不止宗教和传说，但每当谈及文化的时候他指的总是
这二者。他在相关论述中谈道：

根据经验的不同，传说和宗教中投射系统(projective system)的
产物也不同。这就给了我们第一条线索，用同样的方法来研究更多的
现象。

因此如果我们再考察上一段落中的关联，会发现如果儿童时期的
教育构成了制度的一级，宗教和传说就构成了另一级。我们把前者称
为初级制度，而把后者称为次级制度。此外，个体的童年经历也会创
造一些东西，这些东西构成了后来创造传说和宗教的投射系统的基
础。
 虽然钦佩卡丁纳博士的学术建树，但我必须指出，文化的发展是
一件复杂的事情，不能用任何一个简单的准则来涵盖。如此简单的准
则绝不适用于西镇，西镇既长久浸淫于文教遗风之中，又处在中央政
府的影响之下，中央政府严格且持续地在全国推行其品行准则。

但卡丁纳博士并非完全没有意识到其论证的缺陷，即他的论证试
图用文化解释基本人格类型，又用基本人格类型解释文化。我们再引
述一段他的话：

那么关键的问题就变成：是什么决定了父母对孩子的态度，进而
使孩子受到具体影响？通常，我们可以说父母的态度是由社会组织和
谋生手段所决定的。

此说法确乎无误，但严格来说，我们还必须加以若干限定条件，
否则仍可能大失所望。这些条件对文化变迁至关重要。

如果我们试图定义那些决定父母态度的社会经济条件，显然我们
会立刻陷入社会起源的问题。这是一项毫无希望的工作，关于此点，
诸理论无法代替说明性的证据。 （黑体是笔者所加）

卡丁纳博士用以下的话来结束其阐释：

我们所说明的是，基本人格概念的实践价值不仅是诊断塑造人格
的要素，而且为解释这些影响为何如此提供了一些线索。 （黑体是
笔者所加）
 有两件事可以让精神分析学家避免在“一项毫无希望的工
作”和“一些线索”之间摇摆不定。他本可以采取更合理的理论立
场，如拉尔夫·林顿那般，认为文化和人格是一种螺旋式关系。根据这
一观点，文化和人格绝不可能完全一致，但彼此又息息相关。 他可
以不同时解释文化对人格的影响和人格对文化的作用，而是先致力于
其中一个方面以达到更好的效果。如果有人对此方法有异议，认为它
人为地将文化与人格这一整体切分开来，那么通常可回应如下：所有
的科学工作都或多或少地，将本质是一个整体的体系之中的现象划出
一些人为界限。本书的工作是试图确定中国文化对人格的影响——而
非人格对文化的作用。

第三，本书的研究也与卡丁纳博士的研究不同。作为一名杰出的
弗洛伊德主义者，卡丁纳博士理所当然地认为早期教育至关重要。事
实上，他对于投射系统这个概念的强调已经暗示早期教育决定一切。
然而人格和文化都是连续的。文化对于人格的影响贯穿人生始终，不
会半途中止。正如林顿所指出：

任何社会的文化，都通过儿童教育的特定方式，决定了其社会成
员的深层人格，但社会文化的影响并未止于此。同样地，它为社会成
员的特定反应提供模板，从而塑造了其人格中的其他部分。这一后续
过程贯穿一生。

在本书中，文化对于个体的影响不仅追溯至婴儿期，还归因到成
年期和老年期。人格不只是早期教育的结果，相反，它在文化及其制
度中持续发展，并与之融合在一起，因而我们也从此中来阐明它。
田野
从西镇到滇缅公路无论步行或骑马都只消一天。西镇背山面湖，后山海拔约14000
英尺 。西镇平均海拔约6700英尺。该地以农业为主，水稻是主要的农作物。但各式
商贸也兴盛繁荣，是西镇的经济支柱。西镇的贸易方式既包括集市上本土货物的互通有
无，也有和外地大规模的商业合作。

西镇是一个农村集镇。它最早出现在中国历史上是在距今约1000年前的唐朝。现
如今，西镇由它南边的一个县政府所管辖。当地的行政首脑称作“镇长”（乡镇的头
儿）。理论上，镇长由人民选举产生，再由县长任命。实际上，通常是县长直接拣选一
个镇长，民众也就默认罢了。

西镇人口约有1000户，合计约8000人。这些家户被划分为10保，每保约100户。
每保有一保长。一保又分为10甲，每甲10户，每甲又有一甲长。与镇长相比，保长和
甲长才更称得上是真正由民众选举产生。

西镇本身没有城墙，看起来并不十分规整。镇内仅一条主街，南北贯通。其余街道
皆东西走向，与主街相连，间距不等。几年前镇上修了四个大门，主街两头各一个，东
边和西边其中一条街的街尾各一个。这样一来，待到夜晚，镇里雇佣的人持枪巡街时，
镇上大部分地方就与外界相隔了。但西镇的居民不全住在四门之内，门外至少有九个明
确的群落，每个群落叫作一个村。四门之内，每条街道或一条街道中的各个里巷，也可
认为是一个村。

镇长负责镇上的公事。他手下有一支小规模的警察队伍，由镇财政负担。镇上居民
的民族起源是个悬案。总体而言，此镇、此县及其治下各个村落是云南白族（民家）的
一个聚居地。但在西镇和附近九个村中的八个村，所有住民都坚称他们源自汉族。他们
之中还流传着祖辈从中原省份迁往云南的传说，最常见的祖籍是“南京”，但此南京与
现在的南京几乎没有相似之处。少数族谱记载他们的祖先来自安徽省。就此关联，19
世纪90年代初英国人戴维斯(H. R. Davis)少校的观察最为有趣：
 汉族移民，或以军事征服、屯垦戍边的方式征战至此，或受中国政府之命从帝国他
处迁至此省。除此以外，家庭甚至个人往往以农民或商人的身份于非汉族部落定居。无
论哪种情况，汉族移民都必定要与原住民通婚，于是说汉语、守汉俗的混血民族就在此
生根发芽。几代之后，这个混血民族就会自称为汉人，并愤然反对自身有其他部落血统
的说法。

并且，随着汉族的影响和文化的传播，邻近部落觉察到学习汉语、接受汉人习俗的
便利。最终，他们中的一些人开始鄙弃本族的语言、习俗和服饰，并以汉风为荣。当这
一观念在他们脑海中成形，他们自称为汉人也为时不远了。一个毫无汉族血统的汉族就
形成了。

这一过程在中国西部至今犹存。甚至可以看到一些部落正处于转型的各个阶
段，……其中大多数……中国西部部落的男性深受汉族影响，以至身着汉人服饰。妇女
的情况则不同，妇女的衣饰往往是区分不同部落的独特标记。

男性穿汉人服饰后，接着便是学习汉语。几代之后可能连妇女也会学习讲汉语。一
旦达到这个阶段，不用多久这个部落就会完全采用汉人的生活方式，当妇女穿上汉人服
饰，裹上小脚，就完成了转型……

我在倮倮族、掸族、拉祜族中都看到了这一过程……这个过程无疑在中国西部的几
乎每个部落都发生着。因而帝国此处的汉人实际上是非常杂糅的民族，他们使用汉语绝
不意味着他们自我认同为汉人。

毫无疑问，自生活在中国这块土地伊始，汉族同化其他民族的过程便已在中国全境
展开了。

就西镇情况而言，文化渗透的发生顺序似乎与戴维斯所观察到的不尽相同。西镇无
论男女都着汉人服饰，年届三十的女性均裹脚缠足，但人人皆以民家话为母语。此外，
大部分男性与较少的女性说带有当地口音的云南方言。
 图1 西镇

无论我们在具体情况上是否同意戴维斯的判断，也无论西镇人究竟是汉人与原住民
的混血后裔，还是接纳了汉族文化的纯原住民，都无关紧要。总之，这里的现实与戴维
斯的观察合若符契。西镇人坚称自己具有汉族血统，而且会被他人流露出的怀疑所激
怒。西镇人强调男女有别，对于未婚女子的贞洁和已婚女性的妇德极为重视。西镇人还
把祖先崇拜体系化到令人惊诧的程度。有钱有势的人家，乃至平民百姓都要修建祠堂。
家家户户都为挑选风水好的墓地费尽心思。 旧帝国自北京赏赐下来的荣誉曾经是尊
荣，至今仍受人尊崇。在中国的其他地方，一个家族刻匾悬挂的都是自家人（往往是两
三代以内的成员）获得的荣誉。每项荣誉只在一个家宅的一扇大门上的一块牌匾上得到
陈列。在西镇则不同，每一项荣誉都刻在好几个家宅的大门牌匾上，许多人家挂的匾是
同宗的十代先祖或更久远的先人所获得的荣誉，这些先祖生活在明代，甚至元代。若是
并无真正的荣耀，人们经常编造一个来替代。诸如此类以及许多其他事情都表明西镇人
不仅在文化意义上是中国人，而且倾向于坚持他们在许多方面比诸多中国其他地方的汉
人还更像汉人。

西镇与中国大部分乡镇不同的一点是这里的富庶人家异常之多。有些家庭不仅在当
地闻名显赫，而且在省里的大城市和省城昆明都声名远播。几年前一户首富人家办丧
事，前后长达两个多月，耗费约一百万元。当时大学教授的月薪也就四五百元。

即使小家庭的收入也颇为可观。那次无比奢靡的丧事之后不久，镇上一个小货店的
年轻老板便花费了一万元举办婚礼。当时工人每日的工钱（包餐）约两三元。

财富无疑促进了人们对御赐荣誉、祖先崇拜和其他传统活动的追求。近年来，财富
又让人们兴建了三所现代学校、一家医院和一个图书馆。这些现代公共机构的意义，将
在随后章节得到更清晰的呈现。值得注意的是，这家医院约有20张床位，一名科班毕
业的护士，两名具有相应文凭的医生（其中一名曾在北平协和医学院受训），多名助理
护士，以及一个护士培训班。这家医院为穷人提供免费药品和住院治疗。学校有：一所
中学，一所有两个校区的小学和一所师范学校。1942年，这三所学校一共招生1400
人。中学和小学是男女同校，中学的校长是当地人，曾求学于北平的清华大学。
 尽管有这些现代机构，在我调查期间，30岁以上的男性吸食鸦片的现象仍较为普
遍。 前些年，中央政府的权力尚未达到云南省时，鸦片种植十分泛滥。甚至迟至
1934年，昆明城墙外仍随处可见罂粟田。今天这一景象已不常见，尤其在交通便利的
地方。但我得知，在云南省的偏远腹地仍有鸦片种植。鸦片种植和贸易是从前许多西镇
家庭的主要收入来源。禁绝种植之后，许多小农对逝去的“黄金时代”叹息不已，但这
并没有阻止富裕家庭从日渐稀少的鸦片生意中牟取更多暴利。这至少是西镇富庶的部分
原因。

西镇人惧怕的灾祸约有三类：疾病和瘟疫；旱涝灾害；土匪和战乱。人们主要依靠
神灵的力量来消灾攘祸。镇上居民每年都要定期供奉祭拜神明。下面这张表格列出了一
年中主要的祭祀活动。

表1 祭祀年表
 ㉙指释迦牟尼。“帕”，和尚；“召”，王、主人。——译者注

其中许多节日和中国其他地方的相同，但是在西镇，这些活动不会草草了事，表中
的大部分节日期间，西镇人都要大摆宴席，祭祀活动人山人海。每个这样的节日都有庙
会，在别处可能一年只有三四场。不仅如此，西镇还有一些表上没有列出的祭祀活动。
本主（社区守护神）庙在整个社区星罗棋布。每一位本主管辖一片区域或一个村子，他
们有名有姓，有诞辰。每个本主的诞日都有庆祝活动，除了参与者只有本地受其庇佑的
民众外，其他和表上所列的常规祭祀活动一样，别无不同。

此外有一些其他的场合也要祭祀，如婴儿出生，甚或杀猪。通常祭祀的人家会请来
一位法师念一天经，这叫作“祈求平安”。整场祭祀活动就在家宅外的一个小祭坛前进
行。

有些公共场合只许男性参加；有些只许女性参加。若是一些男女共同参加的活动，
男女就会分别在庙的两边吃饭。农历三月上坟的时候，则是家中男女老少一同前去。

诸如春节、清明上坟和农历七月中元祭祖等节日，则要持续好几天。

如前所述，当地人最害怕三种灾祸。祭祀的目的除了祭祖，还要确保人们和鬼神关
系的融洽，以免他们降下灾祸。但事实上所有祭祀活动都是社区生活的一部分，人们在
祭祀供奉时并不会去寻求特定的目的。另一方面，有一些特别的祭祀活动只会在灾害发
生时举行。我在其他地方已经描述并分析了人们如何应对流行性霍乱。 此外，人们
对抗匪患、兵燹和轰炸，还有地震（曾夺去西镇往南一地数百人的性命）和其他流行病
的方法大致也与对付流行性霍乱的方法相同。不过，应对旱灾的方式则稍有不同。
1943年春天发生了一场酷烈的旱灾，一队人便把龙王爷的塑像从庙里面请出来，巡游
至西镇北边山巅的泉眼旁。龙王爷的前面摆着一条布扎的“旱龙”，后面摆一条柳编
的“水龙”。人们把它们在泉眼旁放上两夜；随后龙王爷的塑像又被请回庙中。这一仪
式的含义是，泉眼遭了害，要让神明亲自前往救治。此活动极为盛大，甚至连其他村的
回民都前来参加。一般来说，西镇人和回民村的人关系并不友好。

所有仪式场合都包含为当地人提供娱乐的欢庆活动。即使在瘟疫最严重的时期，霍
乱祈神会上也还有一些娱乐活动。从这一点来看，西镇人有大量娱乐消遣。另一方面，
西镇人无论男女，都没有用娱乐来提高工作效率的想法。镇上和附近地方都没有电影
院、剧院和娱乐中心。南边距西镇14英里的县城有一家滇剧院。但因为交通过于不
便，大部分人负担不起这种奢侈的旅行。

除了仪式庆典，西镇人的确还是有一些娱乐的。晚上，许多店铺还敞开大门，招呼
街坊朋友到亮堂的屋里畅聊；还有三三两两的男性或站或蹲，在街角闲聊，他们经常聚
在一个小吃摊附近。镇上有两三家茶馆，不过它们才刚成为西镇生活的一部分，还不十
分时兴。所以茶馆往往晚上打烊很早。从国家大事和市场价格的流言蜚语，到地方社会
的是是非非，人们在聚会时无所不谈。

通常，年轻人喜欢去店里，年长的人则青睐于聚在街角。于是，店铺里的议论多涉
及市价、战争、缅甸境内和滇缅公路上的冒险以及相关话题，街角的闲谈则充斥着食
物、本地事务和抚今追昔之叹。

集市广场有一家小小的“现代”药房，那里的氛围有些不同。通常过了晌午，一小
群镇里的文人便会光临此地，包括唯一健在的举人。参与此聚会的还有镇上巨富家的公
子（他刚从香港回来）、镇长、警长，以及一些乡绅。

赌博是另一种娱乐方式。直到1943年，三家赌坊生意还十分兴隆。它们晚上营
业，有时白天也开门。其中一家开在一名警察家里；第二家开在了一位保长家；第三家
则位于一间祠堂中。第一家赌坊聚集着中年人和年轻人，他们往往一掷千金，1943年
赌注常常加到五位数。第二家赌坊聚集着各个年龄段的人，一般赌注较小。最后一家只
有年轻人去，他们下注的大小与第二家相仿。玩的通常是麻将和扑克。所有客人，无论
赌博与否，都将获得免费招待——食物、饮料，需要的话还提供一管大烟。

除了在这些赌坊里赌博，西镇人每年又有三天可以公开赌博，日期是从大年初一到
大年初三的晚上。在这三天三夜里，老老少少都挤在几家临时改为公开赌场的店铺里，
赌注有时大得惊人。

女性完全不参与以上这些娱乐活动，她们主要从每年形形色色的祭祀和集市中取
乐。有些集市三天一次，有些六天一次、十二天一次，还有些一年一次。赶集的男男女
女各有各的目的。大部分人是去做买卖的，也有许多人是去询价，或是查验各式货物、
走访朋友，甚至偶尔为了姻缘。我们曾提到过，有些祭祀活动只有女性参加，而有些则
是男女共同参加的。每逢这些场合，女人们就会穿上她们最好的衣裳，举行祭仪，尔后
她们便五六个一起，在庙宇的院子里围坐成一圈，分享刚刚献祭给神明的丰盛供品。

滇缅公路通车以前，这里罕有人知晓汽车运输。要去昆明，只能步行、骑马或是坐
人力轿子，约莫得花两三周的时间。公路竣工后，西镇很快就通过一条支路与之相连
了。但很少有小汽车和卡车走这条支路，从西镇到滇缅公路主要的交通方式还和以前一
样。

但即使在滇缅公路修建以前，西镇也已有了一些现代化的影响。几年前就有了邮
局。当地人家的儿子远去北平、上海、香港、中南半岛，甚至日本和美国求学或经商，
他们往往会带回来新的观念、新的生活方式。医院和学校在二战前就有了。如今，30
岁以下的镇民中，抽大烟的男性和裹小脚的女性已经相对很少了。

战争无疑打乱了许多旧的社会常规(social routine)。首当其冲的是征兵，有些家庭
成功逃了过去；其次，邮政服务变得愈发频繁；最后，一所教会学校避难至此，其中许
多学生来自长江下游省份，教职工既有英美传教士，也有中国人。随着这些外乡人而来
的是更宽松的两性关系、教堂礼拜、无线电、医疗救治、新式服装，以及其他新潮事
物。

除教会学校的教堂外，还有两座教堂。其中一座由美国圣公会资助建立，另一座则
由一所神学院资助。另外还有一群自称为“基督徒聚会处”(the Little Flock)的人也在
积极传教。

不过，传统的力量依然强大。有一件事仍被人们说得活灵活现：1943年，一位从
香港回来的年轻人和新娘手牵手走在街头时被人当头泼了一桶粪水。按照社区的习俗，
这种自由行径是不能容许的，所以这对年轻新人并没有因这种粗暴的对待获得任何赔
偿。

古老习俗在生活的其他方面也占有统治地位。例如，公共卫生完全缺位。直到
1943年，镇里还随处可见病狗，驴粪、马粪、骡粪到处都是，儿童甚至成人都在主街
和任意路边随意大小便。没有人会劳心打扫街道。大约6年前，教会学校和本地中学联
合起来组织了一场公共卫生运动。这些学校的老师、学生清理了所有道路，杀了大约
50条流浪狗。不少居民支持该运动。同时，一些学生走上街头宣讲这项运动的重大意
义。在那之后的一段时间里，成堆的粪土和其他不干净的东西在镇上消失了。但生活旧
俗慢慢又卷土重来，现在连记得当年那场运动的人都很少了。

1英里约合1.6公里。——编者注
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 McBurney had assisted Sands in a large number of cases, and in 1889
published his classical paper with an account of “The First Recorded Case
where an Acutely Inflamed Appendix had been Removed while Full of Pus.”
In the same year Weir also published an elaborate paper, making similar
recommendations. It is not necessary to follow the subject later than the
year 1889, since to it every surgeon of note has probably contributed.

Anatomy.—The vermiform appendix is an embryonic relic, and,

like all such remains, is not merely superfluous, but
often troublesome. That at some time it may have had an ordinary
function is not to be denied; that now, in quadrupeds at least, it has
one cannot be successfully maintained. Its past importance may,
however, be perhaps indicated by the fact that in the ostrich, for
instance, it is said to assume a length of six feet. Because of its
relatively wide variations in size, length, and emplacement, as well
as because of its mesenteric and other anatomical arrangements, its
affections are often complicated and variable in the symptoms they
produce. The appendix is, in fact, a miniature intestinal tube, having
the same structure as the small intestine, though but greatly
reduced. Its average length should be 8 to 9 Cm., the shortest on
record being 1 Cm., and the longest perhaps 24 Cm. Its average
gross diameter should be that of a No. 16 French catheter, but it may
be found 1.5 Cm. in size. The average diameter of its lumen should
be 1 to 3 Mm. The appendicular artery is given off from the right colic
branch of the ileocolic artery, and it ordinarily divides into four or five
branches, according to the length of the appendix and the extent of
its mesentery. It derives its nerve supply from the superior
mesenteric plexus of the sympathetic ganglia, which itself is
connected with the right pneumogastric, this fact explaining many of
the reflexes accompanying its diseases. In it lymph abounds and
lymph follicles are numerous. Around its neck, as around the origin
of every other embryonic canal (as Sutton has shown), is found a
collar of lymphoid tissue corresponding in structure to that seen in
the pharynx. This tissue is inflammable, and succumbs easily to
infection. Hence probably the apparent ease with which infection and
gangrene occur in this locality. The position of the appendix is
variable, and depends in effect on the development of the cecum
and the degree of its rotation during this process. Its most frequent
location (40 per cent.) is behind the cecum. In 30 per cent. of cases
it occurs on its anterior surface or just at its lower end. It may lie as a
free pouch with a loose mesentery, movable in the abdominal cavity,
or it may be essentially a retroperitoneal affair not only not free, but
even difficult to find. In direction it may vary correspondingly. Thus it
may lie behind the colon, perhaps pointing straight upward toward
the liver; it may hang in the pelvis, it may point toward the sacrum, or
it may coil up anteriorly; and, according to the extent and freedom of
its mesentery, in any of these locations, it may either be unattached
and movable or quite bound down. Again, it may lie nearly straight or
it may be kinked, bent, or coiled. It is necessary that the surgeon
appreciate these possible variations, for they account for vagaries in
symptomatology. In brief it should lie in the iliac fossa, at least, and
to the outer side of the iliac vessels, but it may hang over into the
pelvis in 20 to 25 per cent. of cases, or its tip may rest in a pocket or
even in a subcecal fossa. In other words, it may be found in almost
any attitude or position, these variations being explainable by
peculiarities of fetal development. Furthermore it may even have its
own diverticula, as has been recently shown. Normally it should be
practically empty, save perhaps for a little muddy mucus. Very
frequently, however, it contains fecal matter, and upon this fact
depends much of its importance. If from retained fecal matter fecal
concretions gradually result, then these become irritants and may
produce either appendicular colic or may predispose to acute
infection. Upon the retention of fecal contents should depend also a
miniature peristalsis, and imitation of what goes on in the intestine
above, in the production of a genuine appendicular colic. How
annoying, painful, or even disabling this may be may be learned from
the history of many a patient. On the other hand the appendix may
become gradually occluded or obliterated, in whole or in part. If this
process begin at its distal end and involve the entire tube it might be
considered a fortunate occurrence for the patient. If, however, it be
due to previous inflammation, or to subinvolution of the previous
process, and if fecal concretions be thus imprisoned, it is hardly
desirable and will frequently lead to trouble. More or less occlusion
occurs in probably at least one-fourth of mankind.
 Like the bowel above, the appendix may suffer in various as well
as in similar ways. Thus in it may be seen pathological conditions
which involve the bowel proper. Tuberculosis and actinomycosis may
even occur here as apparently primary lesions, while cysts have
been discovered within its walls, and such tumors as fibromyomas or
primary adenocarcinomas are also met here. I have seen three or
four instances of primary cancer of the appendix, and have now
living one patient from whom six years ago I removed an appendix
and adjoining portion of the cecum involved in most distinct cancer.
Again, the appendix participates in certain hernias and has been
found in instances of strangulated or non-strangulated inguinal and
femoral hernia, and has been seen also in cases of umbilical hernia.
Twice I have found it in the inguinal canal and once in the femoral.
Furthermore when diseased the appendix, like the bowel, may
contract adhesions to certain viscera, while it is now well known that
it may attach itself to the kidney, the bladder, the right ovary, the
tubes, or the uterus. This is of more than mere passing interest, for
by such adhesions cases are not only surgically complicated, but
diagnosis is made difficult, because of associated symptoms pointing
to the organ thus involved.
Foreign Bodies in the Appendix.—Foreign bodies are
occasionally found. This
expression refers not merely to the fecal concretions above
mentioned, which are practically small enteroliths. Thus, Kelly has
mentioned cases in which ordinary pins have been found in this
location, two of these cases being my own. In one instance I found
the appendix to contain a round-worm at least three inches in length,
and other intestinal parasites have been found by other observers.
The laity have been greatly impressed by the reputed frequency with
which grape and other seeds are found in the appendix, these
figuring in their eyes as exciting causes of disease. In truth seeds
are seldom found, that which has been mistaken for them being fecal
concretions of various sizes and degrees of density. I have found
actual seeds two or three times, but probably not oftener.
Bacteriology of Appendicitis.—Acute appendicitis being
essentially an acute infection one
inquires naturally which are the organisms most commonly involved.
Answer to this question should be sought rather in the text-books on
pathology, and should be summarized here by simply saying that the
colon bacillus is perhaps more often found in connection with these
cases than any other one organism. Streptococci and staphylococci
rank perhaps next in frequency, while the pneumococcus, the
capsule coccus, and all of the other pyogenic forms may be present,
either as contaminations or in almost pure cultures. The fauna and
flora of the intestinal tract afford ample opportunities for
contaminations with many forms of microbes. If pus found here be a
pure culture of any one organism it is most often of the colon variety,
which is known to vary much in virulence, even when occurring
alone. Mixed infections, however, are more predominant and more
serious, especially in proportion as the more active pyogenic
organisms appear in greater numbers. The bacteriology of
appendicitis is then of great pathological interest, but concerns the
surgeon very slightly, unless he have to do with some peculiar form,
such as pyocyaneus, or a particularly virulent streptococcus.
PLATE LI
 Illustrating Various Degrees of Involvement of
Appendix Vermiformis. (Richardson.)
A. Chronic, recurring.
B. Chronic, much thickened.
C. Acute, with necrosis and rupture.
D. Showing necrosis of mucous membrane.
E. Gangrene and perforation, permitting fecal extravasation.
F. Total gangrene without perforation.

Appendicular Colic.—Sufficient has been said above regarding

the appendix as a miniature intestine, its
outlet guarded by the little valve of Gerlach, to afford an anatomical
reason why conditions even in the larger bowel should be imitated
here. Some writers have not placed as much stress upon
appendicular colic as I would here. One sees many instances of it if
he will only recognize it, the frequency of its occurrence not only
disturbing the comfort of patients, but keeping ever before their
minds the necessity for operation. An absolutely empty appendix will
be free from all abnormal activity of this kind, but when a little fecal
matter has become imprisoned, and when by its long retention fecal
concretions have formed, they may give rise to considerable
disturbance without actually producing inflammation, the former
being due to the spontaneous effort of the appendix to expel them.
This effort may be excited by other conditions in the bowel adjoining,
but by itself it may be the essentially relatively violent muscular effort
which produces pain and is followed by soreness. That not a few
cases of acute appendicitis commence with an appendicular colic is
extremely probable, and that it may occur at frequent intervals and
never pass the colicky stage is equally true. Appendicular colic, then,
may be a precursor of an infectious appendicitis, acting as a
predisposing cause, or either may occur independently of the other.
 Indications of this form of colic are frequent, viz., nagging pains in
the region of the cecum, which may last a few moments or a few
hours and then subside, leaving a tenderness which persists for a
day or two, after which the patient seems to be free for a longer or
shorter interval, to suffer again and again in the same way. These
attacks may be accompanied by some nausea, will be found
frequently associated with whatever may have disturbed ordinary
intestinal activity, and may even produce a mild degree of fever,
which latter is partly due to mental perturbation and partly to a mild
degree of toxemia, the latter being possible in connection with
abnormal appendicular activity, as the appendix itself is a closed sac
and the very materials which it is trying to expel may furnish the
toxins.
It is difficult to distinguish between appendicular colic and mild
attacks of catarrhal appendicitis. The transitory nature of the former
is its particular diagnostic feature, coupled with absence of all lasting
indications.
The following would seem the simplest working classification of
lesions of the appendix.
Catarrhal. Endo-appendicitis.
Hyperplastic.
Diffuse. Parietal or interstitial. -
Obliterative.
Intertubular.
A. Acute. - Purulent. - Intramural.
Peri-appendicular.
Any of these may lead to
Gangrenous or
Perforative lesions.
B. Subacute. Recurrent or relapsing.
C. Adhesive or obliterative.

Almost any of the above forms may be associated with diseases of

other abdominal viscera, as, for example, with typhoid. Thus out of
119 autopsies on typhoid patients 19 showed changes in the
appendix corresponding to those produced by the typhoid organisms
in other portions of the intestines. (Kelly.) Of 3770 autopsies on
tuberculous patients tuberculous lesions were noted in the appendix
in 44 instances. The appendix may also become involved with any
form of ileocolitis, either in the young or in the adult. Again an
infection of the right tube and ovary may easily extend to and involve
the appendix, just as infection may travel in the opposite direction.
(See Plate LI.)
Before discussing the causes of this condition it is advisable to
take a comprehensive view of the entire subject in its pathological
relations. As Dieulafoy has shown, appendicitis is the consequence
of the transformation of the hollow conduit into a closed cavity,
whose length and narrowness make it liable to such changes, for
which various causes are to be assigned: for example, the formation
of calculi or concretions which are quite comparable to renal or
biliary and which lead to a true appendicular lithiasis. There is even
reason to believe that a calculous appendicitis may be hereditary
and belong to the patrimony of gout. At other times it is the
consequence of local infection, followed by tumefaction, and
corresponding to obstruction of the Eustachian or the Fallopian
tubes. Again it results from slow, progressive fibrous alterations or
from the strangulations due to twisting or formation of adhesions. In
any event the closed cavity varies in size and shape, and does not
necessarily lead to self-destruction unless the bacteria thus pent up
are sufficiently virulent. At all events the attack declares itself only
when the cavity is actually closed, and it is then that imprisoned
bacteria, previously harmless, multiply and intensify their virulence,
as they do in a blocked loop of bowel. At times an acute intoxication
from toxins is produced, and may be so pronounced that patients
succumb to it almost before the characteristic lesions, or any local
peritonitis, has become fairly outlined. On the other hand if retained
bacteria be but slightly virulent, or have been successfully conquered
by phagocytes, or if the canal has become pervious again, the attack
may spontaneously subside, although there is great probability of
recurrence. In many instances the infection ends in ulceration,
abscess, gangrene or perforation, all of which may give rise to
peritonitis of varying extent and severity. Germs may traverse the
walls of an affected appendix without perforation. It may then
become the direct cause of peritonitis, septicemia, or hepatic
abscess.
 Recurrent Appendicitis.—Every attack of appendicitis, no matter
how mild, predisposes to a repetition of
the trouble, in mild or in fulminating form. Every appendix once
inflamed has had its blood supply compromised and may break
down easily upon a second attack. While not every patient who has
once suffered in this way should necessarily suffer again, the
majority who have had one attack may have another. No one can be
prophetic in this regard and no one may truly assert that several mild
attacks may not be followed by another most severe. That an
appendix has been once inflamed is sufficient to justify its
subsequent removal. That it has been several times involved makes
operation next to imperative. Even repeated attacks of appendicular
colic predispose to trouble in this region. In any appendix which has
in this way frequently excited suspicion, or which gives rise to
frequently recurring though mild colicky pain and local tenderness,
especially when coupled with mild stercoremia, indications are for
removal. It may be safely laid down, then, as a rule, to which there
should be few exceptions, that any appendix which causes
frequently recurring or almost continuous trouble should be removed.
Causes.—It is impossible in any brief summary to include all the
possible causes of appendicitis. Those mentioned below
are perhaps those most commonly recognized or pronounced, yet
the list is far from complete. First of all it should be remembered that
the disease occurs in a vestigial organ, containing relatively
considerable lymphoid tissue, especially around its neck, that it is
comparatively poorly supplied with blood, and that such tissue under
such circumstances inflames easily and breaks down quickly.
Doubtless the trouble in some instances commences within the tiny
intestinal tube. At other times its originating cause lies without, as, for
instance, when its blood supply is interfered with by pressure of an
overloaded cecum, by tumors, or by violent intestinal activity; this
especially in connection with an appendix firmly anchored and not
freely movable, it being so fixed in many instances that it cannot
readjust itself easily to varying conditions. Thus an overloaded
cecum may first press upon the appendix and then by violence of
activity so displace it that it may easily succumb. Again in those
appendices which hang downward into the pelvis there is little or no
drainage by gravity, and they may easily become overloaded. A
movable kidney may also disturb the integrity of an appendix in
certain locations. Foreign bodies frequently excite pernicious activity,
especially fecal concretions, and actual calculi or miniature
enteroliths. Traumatism sustains a certain relation to some cases of
violent activity of the psoas muscles in athletes, which may upset the
circulation of appendices which lie directly upon the muscles
involved.
Many of the causes mentioned above are predisposing rather than
actual. The actual exciting causes of acute infection have mainly to
do with germ activity and with vascular supply. It is well known that
the more virulent the organisms the more acute the resulting
inflammation, and it is also well known that colon bacilli and the
ordinary pyogenic organisms vary in virulence within wide limits, and
that mixed are often more acute than simple infections. Typhoid
bacilli, tuberculous bacilli and the like vary in the same way, and, in
company with other germs, may easily light up serious disturbance.
Complications.—Of the complications which may accompany or
ensue upon appendicitis the most common are
those which involve the peritoneum, either local or general. Acute
peritonitis is to be feared not only because of its autotoxic
expressions, but because of the acute obstruction which it may
produce by gluing intestinal loops together and paralyzing their
motility. When to more or less widespread peritonitis are added
general sepsis, with all its possible complications, and such further
local expressions as cellulitis, which may be pericolic, subphrenic,
perineal, or pelvic, or phlebitis which, involving the portal system,
would soon lead to formation of hepatic abscess, it will be seen how
easily the case may become serious. Furthermore not only may the
ovary and tube suffer, but cystitis and nephritis may occur as toxic
complications, while finally, by violence of the ulcerative process, a
fecal fistula may form. This is by no means a complete list, but
includes some of the more frequent complications.
Symptoms of Acute Appendicitis.—Pain with nausea,
tenderness, and rigidity
constitute the triad of the most indicative early signs and symptoms,
each of which needs to be considered by itself.
 Pain.—Pain is at the same time an important yet variable feature. In
few other acute lesions does it vary as much in degree and location.
Generally it is referred at first to the more central portion of the
abdomen, as around the navel or between it and the right side of the
pelvis. Later it may be localized at some widely distant point, as, for
instance, far over upon the left side. Such vagaries may be held to
be due to peculiarities of emplacement of the appendix, and would
indicate that the organ will probably not be found in its most common
location, but rather extending to the left or hanging over into the
pelvis. When the appendix is attached to or lies near the bladder
there may be considerable pain in the pelvis and in the bladder. It
should be remembered that the parietal peritoneum is much more
sensitive than the visceral, and in proportion as the lesion
approaches the surface more exact information may be gathered
from location of pain. Occasionally it may be referred to the region of
the gall-bladder, or even to the chest above the diaphragm. In some
instances it is agonizing, almost from the outset; in others it is never
very severe. The rapidity of the process may be measured to some
extent by the intensity and character of the pain. When the disease
resolves slowly and kindly pain gradually subsides, but the sudden
subsidence of pain, especially without equal improvement in other
respects, is a bad rather than a good sign, indicating probably that
perforation has occurred.
Tenderness.—Tenderness is a more constant and persistent and,
therefore, a more reliable indication than pain, and, as well, less
misleading. No matter where the patient may seem to feel pain the
actual tenderness will indicate the location of the appendix itself.
Thus even if pain on the left side be severe, tenderness will not
accompany it, but will be found centred at the location of the
appendix. This is a fact of great importance. In his first paper on
appendicitis McBurney showed that the appendix is most commonly
located at a point beneath a line drawn from the umbilicus to the
anterior superior spine and one and a half or two inches away from
the latter. This has since been known as McBurney’s point. To it,
however, too much importance should not be attached, since the
appendix is often not found under this area, and tenderness may be
found at a distance two or three inches away from it. Over the
actually tender area the skin will also be hypersensitive, and this
intense hyperesthesia is also an indication of considerable value.
Rigidity and Muscle Spasm.—Rigidity and muscle spasm are to be
carefully studied, and upon them much reliance may be placed. With
the first onset of pain they may be general, but they usually become
more and more localized, unilateral, and finally limited, save in those
instances where general peritonitis has begun and is spreading. For
instance, Richardson regards it in this light: “Rigidity with distinctly
localized pain strongly suggests appendicitis; with fever it almost
proves it; with tumor it fully establishes diagnosis.” When to ordinary
abdominal rigidity is added actual muscle spasm, provoked by even
light palpation, and occurring in the rectus or one of the flat muscles
lying in close relation to the appendix, then a still more important
indication has been obtained. When true muscle spasm involves all
the abdominal musculature general peritonitis has probably begun.
Tumor.—The presence of tumor in the suspected area will nearly
always be a corroborative sign, but diagnosis should not depend
upon its presence. It is hardly to be looked for during the early hours
or perhaps days of an ordinary attack. It may be due to fecal
impaction in the cecum, to outpour of exudate, to binding together of
omentum and intestine, or to the presence of pus. If a considerable
mass can be detected within the cecum during the early hours of an
attack this should be regarded rather as an expression of
coprostasis and impaction, to which the attack itself may be due.
Tumor, therefore, is significant when present, while in some
instances its absence is still more so.
Vomiting.—Vomiting is an irregular and uncertain feature. Probably
the majority of cases begin with nausea (after the initial pain) or with
vomiting, either one without the other, or with both combined. Likely
through the course of the disease vomiting may be an occasional
disturbing element, though patients may have no nausea whatever.
Bowels.—The condition of the bowels and their behavior will
depend very much upon their actual state at the moment of attack.
Some attacks seem precipitated by violent intestinal activity; here
diarrhea or dysentery will be an early feature. Others are precipitated
rather by overloading of the cecum; in these cases constipation
would be a well-marked feature. Bowel inactivity is to some extent an
expression of bowel paralysis due to toxemia, which in some
instances is profound, in others slight.
Temperature.—The temperature is also a variable and uncertain
feature. It may be normal at first or very high. At any time it may rise
gradually or suddenly, and may subside in the same atypical way.
Taken by itself it is an unreliable feature. When, however,
temperature steadily rises the surgeon may take alarm, and if the
pulse rate goes up correspondingly the case takes on a serious
aspect. A sudden fall of temperature is almost as serious a feature
as a sudden rise. A normal or subnormal temperature may be seen
when a large amount of pus is present, or but a minimum of
disturbance may be found when operating upon a patient whose
temperature is 104°.
The Pulse.—The pulse is a more reliable guide than any obtained
with the thermometer, its rapidity being proportionate to the gravity of
the disturbance. A constantly rising pulse is a serious indication,
especially if accompanied by vagaries of temperature. Some
operators regard the pulse as a sufficient indication for operation,
holding that when it rises above 112 operation should be made. I
hold this to be a good rule, but would not have it interpreted as
indicating that operation should not be done unless the pulse attains
this figure, and believe that, no matter what the other conditions, the
final indication has arrived when the pulse goes above 112.
Abdominal Distention.—Abdominal distention may be due to gas
formation, to constipation, or may indicate the paralysis of peristalsis.
When it becomes well marked it is a serious indication, and when
toxemia is profound no sound whatever will be heard within the
bowels thus distended. It usually indicates the onset of general
peritonitis. It is unfortunate in more than one respect, since intra-
abdominal conditions are masked by it and operation complicated, it
being sometimes impossible to restore the bowel to the abdomen
without at least partially emptying it.
Jaundice.—Jaundice, when occurring, is a toxic expression,
possibly due to temporary obstruction of distended or paralyzed
bowels.
Finally the general appearance of the patient will be suggestive,
patients with serious conditions having always an anxious or
haggard facial expression, rarely moving themselves easily or freely
in bed, or smiling at anyone or anything, their faces being perhaps
somewhat flushed, their expression and action being apathetic, while
perhaps later there will be delirium with restlessness. When the face
is pinched, the eyes sunken, the nose sharp, the skin dusky, and
respirations rapid and unsatisfying, as well as of thoracic type, any
intra-abdominal infection may be regarded as serious and
unpromising.
What shall be said about the value of the blood count? It is
possible in nearly every instance to make a diagnosis of appendicitis
without the aid of the microscope, as well as even to judge of the
advisability of immediate or postponed operation. Nevertheless an
indicative differential blood count, an affirmative result of the iodine
test, or the discovery of indican in the urine, may afford positive
corroboration in cases where doubt may have existed. In reality,
however, any case which will furnish satisfactory and distinct
responses to these tests should be recognized without them. A
leukocyte count above 12,000, in connection with other indications,
is usually sufficient to justify operation. A very high leukocytosis—
e. g., above 24,000—is a matter of great importance. In the more
chronic cases the leukocytosis is but slight.
Diagnosis.—Obvious and indicative as many cases of acute
appendicitis are from the outset, there are still others
when one may be in serious doubt, even for some days, either
because patients do not clearly state their own symptoms, because
of peculiar reference of pain, or because of the co-existence of
complications, each of which may mask the other.
Colitis of adults and enterocolitis of children will produce
sometimes severe attacks of pain, with cramps and local tenderness,
that may at first mislead. There is a form of mucous colitis which is
now more generally recognized than in time past, in which diagnosis
is sometimes quite difficult. The onset is often sharp, while the right
iliac fossa may be occupied by an elongated, resistant, tender mass,
showing fecal impaction within the cecum. On the other hand the
same condition may be met in the left iliac fossa, and will thus
indicate that the sigmoid is especially at fault. In these conditions
there is often actual exudate around the inflamed bowel, and this
may even break down; it is proper then to speak of a circumscribed
colitis, and there is reason to think that in certain cases it arises from
infection of a diverticulum from the large bowel. The pain is not
infrequently complained of at the so-called McBurney point. In not a
few instances the appendix has been removed when under perfectly
natural suspicion, and found so slightly involved as to show that the
actual trouble was in the cecum rather than in the appendix itself.
Dieulafoy believes, in fact, that formerly the cecum was made too
much of and the appendix disregarded, while today these conditions
are sometimes reversed.
From gallstone disease and cholecystitis its symptoms are
sometimes quite difficult to distinguish. Especially is this true when
pain is not accurately localized, and when, on the other hand,
muscle spasm and tenderness are widespread. The previous history
of the case will give much aid in this matter, while the pain in
gallstone trouble radiates rather toward the right shoulder, in
appendicular disease toward the umbilicus or downward. When
dulness on percussion shades directly into liver dulness the gall-
bladder is naturally the more to be suspected. When patients
themselves cannot make minute distinctions in description of pain
and tenderness the condition may be difficult of recognition.
Peritonitis.—The majority of all attacks of so-called idiopathic
peritonitis spring from appendicular disease, at first and perhaps
throughout unrecognized. A condition of peritonitis, then, for which
other explanation is not found may be considered as, in all
probability, due to appendicitis whose peculiar features may have
been masked. It is not difficult to recognize a condition of general
peritonitis. The great difficulty is to ascribe its proper cause. As
already and elsewhere indicated these conditions merge into
expressions of acute obstruction which still further complicate the
case, and it is by no means infrequent to have this order of events:
an acute gangrenous appendicitis followed by local peritonitis, with
adhesions, which, becoming dense, rapidly produce obstructive
symptoms, the condition going even farther and gangrene spreading
from the appendix proper to any or all of those intestinal loops which
come in contact with the primary focus, so that when the condition is
thoroughly revealed it is found to be one of multiple gangrene of the
bowel as well as of fierce and septic peritonitis.
Gastric and intestinal ulcers with perforation are easily mistaken
for appendicitis, especially when the duodenum is involved. In at
least half of the recorded cases of perforating duodenal ulcer the
condition has been at least at one time supposed to be one of acute
appendicitis, while after perforation has occurred and the matter
which has escaped has worked its way down toward the right iliac
fossa the similarity of conditions will be all the more striking. If an
accurate history can be obtained there will probably be learned from
it that which will tend to avoid mistakes. The exceedingly abrupt and
acute onset of symptoms will also be more pronounced than in most
cases of commencing appendicitis. This is true also of the
perforations of typhoid ulcer, especially of “walking typhoid.” While
acute appendicitis during the course of typhoid is by no means
unknown, the abrupt onset of pain, rigidity, and tenderness during
the third week or later would suggest perforation very much more
than the possibility of an appendical lesion.
Acute obstruction of the bowel due to other causes than
appendicitis—e. g., volvulus or intussusception—might give rise to
symptoms which would be regarded as indicating appendicitis. This
is true also of strangulated hernias, especially the internal forms,
since there will be no excuse for failing to discover an external
strangulation of this kind. Lead colic may simulate some of the milder
and more chronic forms of appendicitis, from which it should not be
difficult to exclude it by its history, the occupation of the patient, and
the appearance of the gums.
The kidneys and ureters are sometimes so involved as to occasion
doubt. A floating kidney, with its possible crises, displaced into the
right iliac fossa, where it might be mistaken for an inflammatory
mass, might thus cause some hesitation. So also might the acutely
suppurative forms, the formation of a sudden phlegmon about the
kidney, or the entanglement of a calculus, either at the hilum or along
the ureter, produce severe pain, tenderness, and fever, which would
at first easily perplex. The pain of renal colic, however, is usually
more agonizing, beginning in the flanks and referred down along the
ureters to the genitals and the inner side of the thigh. It may also be
intense in the back, and may be accompanied by nausea and
vomiting. Renal colic is also nearly always accompanied by frequent
urination and sometimes by the appearance of blood in the urine.
With an impacted calculus at the lower end of the ureter at the level
of the appendix diagnosis may be very difficult. Here the x-rays may
afford some assistance.
Acute pancreatitis begins with intense abdominal pain that may at
first suggest appendicitis. The pain, however, is usually epigastric;
abdominal distention comes on early; vomiting may be profuse, and
the tenderness is most marked along the left costal border. There is,
moreover, a more profound prostration, sometimes accompanied by
cyanosis. An acute suppurative pancreatitis may soon be followed by
peritonitis, which when seen will so completely mask all symptoms
that diagnosis as between the two is quite impossible, but symptoms
which can be accurately localized will usually point to the upper
rather than to the lower abdomen.
Mesenteric thrombosis and embolism are rare conditions which
commence usually with fulminating symptoms and produce intense
agony, with tenderness and rigidity all over the abdomen. Their onset
is so profound that patients fall into a condition of extreme collapse
within the first few hours, and their tendency is so rapidly to the bad
that they are not likely to be mistaken for acute appendicitis.
The pelvic viscera of women also furnish acute inflammations,
such as pyosalpinx, with or without rupture, that sometimes
precipitate very acute symptoms which may point to the abdomen
rather than to the pelvis. In many of these instances the appendix is
more or less adherent to the adnexa on the right side, and infection
in either one may easily travel to the other, so that both become
ultimately involved. Local examination will reveal the existence of
pelvic conditions, in whose absence there may be justification for
inferring that the trouble has not originated in that cavity.
Ruptured extra-uterine pregnancy has been in numerous cases
mistaken for acute appendicitis. It usually begins with violent pain
and pronounced muscle spasm, with more or less shock. I have
repeatedly been called to operate for appendicitis and found the
other condition present. The operator may be prepared to find it if he
elicit a suggestive history or if a vaginal examination reveals a pelvis
more or less filled with semisolid material. Amenorrhea does not
always signify ectopic gestation, yet when doubt arises it would be
advisable to inquire carefully into the menstrual habit of the patient.
On the other hand it is known that acute appendicitis may bring on
uterine hemorrhage. When, however, the possibility of pregnancy
exists, along with a history of menstrual irregularity, or of
hemorrhages unaccounted for, and one finds within the pelvis the
uterus pushed forward or displaced, or perhaps an irregular tumor,
he may suspect the condition if not actually diagnosticate it.
A peculiarly unfortunate combination is that of acute appendicitis
occurring during pregnancy, or still worse, as I have seen it, e. g., in
a woman with a large uterine myoma, gone to about the seventh
month of pregnancy, and then suffering from an acute peri-
appendicular abscess, the whole proving more than she could
withstand.
With an appendix placed behind the cecum it will usually rest upon
the psoas muscle, where it may be disturbed by violent exercise, or
where it may lead to mistaken diagnosis either in case of acute
inflammation of the muscle itself or of acute appendicitis. When the
right limb is drawn up, and especially when all motions of the limb
give pain, we may believe at least in the participation of the muscle
in the inflammatory activity. On the other hand, an insidious psoas
abscess may give rise to a certain degree of tenderness in the right
iliac fossa, with flexion of the thigh, and gradual development of
tumor, which may be mistaken for chronic appendicitis.
The possibility of appendicitis occurring during typhoid has been
mentioned. Differential diagnosis between the two conditions will
ordinarily not be difficult when one can obtain an accurate history. In
classical appendicitis pain is always the first symptom, and
temperature rarely rises until a number of hours at least after the first
attack of pain. Even the milder typhoid cases may show tenderness
in the right iliac fossa, but one should look for the characteristic
eruption and make a Widal test. The presence of splenic
enlargement would point to typhoid, as would also the occurrence of
bronchitis, epistaxis, or headache, with perhaps albuminuria. The
most perplexing cases will be those of perforation, perhaps even of
typhoid ulcer of the appendix. In these cases acute pain will usually
indicate perforation.
Intrathoracic affections sometimes begin with or are accompanied
by severe pains which are referred to various parts of the abdomen
and cause great confusion. Thus I have repeatedly seen pneumonia,
even on the left side, regarded at least at first as acute appendicitis,
because patients referred most of their pain to the abdomen rather
than to the chest, while the abdominal muscles participated to such
an extent as to produce pronounced rigidity. Here a blood count
would scarcely help, but careful physical examination of the chest
would reveal the difficulty. Such examinations should be made when
respirations become irregular, or when the breathing is evidently in
any way embarrassed. Acute pneumonia and acute pleurisy,
especially diaphragmatic, may have then to be differentiated from
acute appendicitis.
Finally, hysteria is an element not to be disregarded in some of
these cases; not that it is likely often, if ever, to lead to serious doubt,
but that patients with the hysterical or neurotic temperament are
constantly tempted to so seriously exaggerate their complaints as to
lead to at least a more serious view regarding themselves than
circumstances justify. Thus a mild appendicular colic in a neurotic
patient may produce a disproportionate complaint, and one must be
ready to assign to hyperesthesia or exaggerated complaints their
proper value.
The symptomatology of appendicitis may then be summarized
briefly as follows: When pain comes on suddenly and is referred to
the lower part of the abdomen, or even its central region, becoming
perhaps more localized as the hours go by, is shortly followed by
nausea or vomiting, and this by general abdominal sensitiveness,
with an increasing degree of rigidity; and when temperature, which at
first is not elevated, begins to rise in from twelve to twenty hours,
then it may be held that this is a classical picture of an attack of
acute appendicitis. So strongly does Murphy, for instance, hold to
this order of events that he even questions diagnosis when
symptoms are not thus timed, and especially if vomiting precede
pain.
 When pain which has been severe subsides, and comes on afresh
after an interval of perhaps thirty-six hours, it is to be regarded as
due to fresh peri-appendicular involvement, and is an unfavorable
feature. In fact the subsidence of pain and apparent improvement
often noted do not always mean actual improvement, but may be the
forerunners of a still more dangerous condition. Thus the “perilous
calm” of appendicitis should hasten operation, or at least increase
watchfulness, rather than beget confidence. Should one rely too
much upon them and procrastinate he will find that his mortality rate
will rise accordingly. The statement elsewhere quoted in this work
that “the resources of surgery are rarely successful when practised
upon the dying,” will apply here.
There is scarcely any equally limited area of the body in which as
many varied and widely different pathological conditions may be
exemplified as in the appendix and the space immediately around it.
The mildest degree of hyperemia or vascular engorgement, the most
destructive form of inflammation, with fulminating necrosis, may here
be observed. Moreover, conditions commencing under one type may
quickly change and the whole type of an attack may within a short
time be merged from the mildest into the most severe.
In catarrhal or endo-appendicitis it is mainly the mucosa which
suffers. This may undergo merely a congestion, with increase of
discharge, and, so long as the outlet be not completely obstructed,
may be a purely temporary matter of but a few hours’ duration, or it
may extend over a few days. The purulent or more destructive forms
may commence in either of the coats of the appendix. It is no
uncommon thing to find a necrotic mucosa with a still unbroken
serosa, or a perforation of the outer coats and a hernial protrusion of
the inner, perhaps just ready to give way. In location and extent the
suppurative and destructive process may also vary. Whereas
ordinarily the distal portion, being less supplied with blood, will suffer
first, it is not uncommon to find perforation at the junction of the
appendix with the cecum, or even gangrene of a limited area of the
cecal wall itself. Again, at times, the trouble seems limited to
accumulation of pus within the appendix, i. e., an empyema of the
appendix, without great tendency to involve the structures adjoining,
and an appendix may be found containing a few drops of pus or