Love, displacement, and ritual excision

A medical anthropologist gets appendicitis

Andrew Russell

Abstract

This is a narrative account of an unexpected illness which occurred at an extremely significant time in my life. Appendicitis is frequently held up as a classic ‘organic’ pathology, one that ‘just happens’ independent of any social and psychological causes or contexts. However, there is an undercurrent of biomedical thinking which suggests that appendicitis may be linked to significant life events, an approach we recognize in medical anthropology as ‘somatization’. This certainly seemed an appropriate inference to make in my case, since my appendix was removed on the same day that my first born son emigrated to Australia. My anthropological background helped me to consider my emotions at the time as a response to ‘social death’, and to reflect on a common anthropological critique of biomedicine, namely that it fails to answer the ‘why me, why now?’ questions patients may so often have of their illnesses. The concatenation of events I experienced led me to question dogmatic assumptions that appendicitis is an ‘organic pathology’ that can only be coincidentally linked to possible psychological or social determinants. However, rather than worrying about the causal explanations that could be constructed, the unfolding narrative led me to consider Jung’s theory of synchronicity and the ‘symbolic density’ that made the onset of my appendicitis and my son’s departure so mutually significant for me. My account thus raises ontological and epistemological questions about supposedly organic pathologies such as appendicitis, and makes the point that, while the number of operations has been falling, appendicectomies can sometimes be associated, at least in the minds and bodies of some patients, with narratives of migration or loss. I found this personally constructed somatization helpful in enabling me to see my appendicectomy as more than just a surgical procedure or unfortunate coincidence. In my own anthropological and Jungian terms, as a ritual of excision it became, unexpectedly, a vehicle through which both physical and psychological healing could take place.

Introduction

This is an autopathography (Aronson 2000), a tale of the circumstances surrounding me getting appendicitis, what happened next, and what I learned from the experience. It is presented in order to demonstrate how my background as a medical anthropologist affected my experience and interpretation of the disease (cf. Park & Van der Geest 2010). It resonates with the ‘why me, why now?’ questions medical anthropologists such as Helman (2001) suggest patients so often have about their illnesses, or the related interest in ‘externalising belief systems’ (i.e. those focusing on causes outside the individual body), a theory developed by Young (1983) to explain how many lay people approach ill health. Helman and Young echo a long tradition in anthropological thought concerning the need people have to ‘make sense’ out of that which may appear difficult or unfortunate. Evans-Pritchard, for example, in one famous passage, writes about the collapse of a granary in Zandeland when people are sitting underneath it:

Why should these particular people have been sitting under this particular granary at the particular moment when it collapsed?…We say that the granary collapsed because its supports were eaten away by termites…We also say that people were sitting under it at the time because it was in the heat of the day and they thought that it would be a comfortable place to talk and work…To our minds the only relationship between these two independently caused facts is their coincidence in time and space. We have no explanation of why the two chains of causation intersected at a certain time and in a certain place, for there is no interdependence between them. Zande philosophy can supply the missing link…Witchcraft explains the coincidence of these two happenings. (Evans-Pritchard 1937: 69-70)

I use the extraordinary coincidence I shall relate in the ethnography which follows not to argue for the power of witchcraft but rather for the notion that, despite being an ‘organic’ disease, appendicitis can be linked to significant life events. I shall also propose, contrary to Sontag (1978), that for the individual patient, making metaphorical associations with diseases such as appendicitis is not necessarily such a bad thing to do, but can actually aid in healing. But first, to tell the tale…

 

Story

In an era of rising divorce rates and easier international travel, the displacement and loss of children from ruptured relationships to other parts of the world must be a growing phenomenon. Ben’s mother and I had separated in 1998 and subsequently divorced in 1999. After seven years with an equal parenting arrangement, as he approached his fourteenth birthday in April 2005, Ben’s mother announced she had got herself a job in Australia and intended to take Ben away with her.

My distress was visceral. Why uproot a fourteen year-old boy from his UK home, a place with friends and family he has known all his life, and remove him to a city 12,000 miles away where he knows no-one apart from his own mother? The ‘contact time’ the equal parenting arrangement allowed – six months a year based largely on regular, half-week stays - was going to be peremptorily cut to two annual visits of about six weeks in total (always assuming I could afford the airfares for these intermittent transglobal reunions). The timings of such visits were likely to be inconvenient too, since the Australian school system ‘back to front’ in its vacation periods compared to Britain. However, Ben’s mother wanted a new life and career in a place free from the emotional trappings of the past and, as Marilyn Strathern (2004:16) remarks, free will is “a force of cosmological proportions in western thought”. After initial tears on hearing the news, Ben himself also said he wanted to go, at least for a period, so there was little to do but acquiesce.

However my relationship with Ben’s mother became increasingly strained. I felt an awful cognitive dissonance in secretly wishing that Ben would dislike his time ‘down under’[note 1]‘Down under’ is the colloquial term in British English for the antipodean nations of Australia and New Zealand
and might decide to return to live in the UK while at the same time trying to support his forthcoming adventure with wan enthusiasm. Eight months ensued with this sword of Damocles – the inevitability of Ben’s final departure – hanging over my head. Everything that happened during this time - holidays, school music competitions, rugby matches, parties, Christmas – carried a poignant sense of being the ‘last’ time, for me at least.

Many friends and family expressed concern for my welfare in the weeks leading up to Ben’s departure and said they would be thinking about me on the day itself. One night in Edinburgh in November 2005 a friend who specialises in death rituals asked me what rituals I was going to perform to mark the departure of my son. It might seem strange and unhelpful to view Ben’s migration as akin to death, but social scientists acknowledge that death in a social sense can be as powerful as death in a biological sense. ‘Social death’ involves the elimination of the social existence of a person in other people’s lives, often quite independently – before or after – biological death (Mulkay 1993). Emigration inevitably involves an element of social death.[note 2]The degree of social death is not necessarily so marked in these days of jet airliners, e-mail, Skype, MSN and Facebook as it was for earlier migrant voyagers from Europe to the antipodes.
The only way I had thought of to mark Ben’s departure was to give him a copy of Tony Parsons’ Man and Boy, a semi-autobiographical novel with its central message that “love means knowing when to let go” (Parsons 1999: 332). This book, inscribed with Parson’s insightful quote, became a Christmas present.

This limbo period came to an end and so it was that one cold and blustery evening in January 2006, Ben’s stepmother Jane, his half-brother Euan (then aged 4) and I took Ben across town to his mother’s house to bid him farewell. Despite the webcam that I had been given by Ben’s mother with the kind intention of keeping us in touch through cyberspace, I told Ben nothing could replace his physical presence in our lives, and that he could come back whenever he wanted (within reason, since 12,000 miles is not conducive to short breaks or long weekends!). “There will always be a light on in the window for your return…”

I felt chewed up inside to put it mildly – and it was then that my appendix started to grumble. At first I put it down to dodgy leftovers or was willing to accept the possibility of psychosomatic stomach pangs. But the bloated discomfort I had felt since lunchtime - which prevented me enjoying the farewell ‘haggis, neeps and tatties’ we had prepared as Ben’s farewell meal that evening - became slightly more localised and persistent during the night, and I started running a low-grade fever. A visit to a perspicacious GP in our practice next morning ended with me driving back home to sort out a few work-related issues before packing a small bag and asking a neighbour to take me to our local hospital in his car.

As a medical anthropologist I was well aware of the rituals and symbols by which I effected the transition from person to patient as I was clerked onto the surgical admissions ward. My hospital gown securely in place, a friendly nurse asked me about my religion (too complicated to say agnostic) and whether I wanted to see a chaplain. The decision to operate for appendicitis was finally taken when blood tests and an X-ray were returned at 6.00pm but, because of an emergency operation ahead of me, I wasn’t wheeled down to the operating theatre until 9.45pm that evening. Ben’s plane was scheduled to take off from Heathrow at 10.00pm. The anaesthetist put a gas mask over my head and told me to keep breathing normally with my eyes open so that they could tell when I ‘went under’. The surgeon told me beforehand that he wanted to do a laparoscopy (keyhole investigation) in case I was suffering from something like Crohn’s disease rather than appendicitis. However, on making the first incision (probably at about the same time as Ben’s flight from London was taking off) and inserting a camera to take a look, he reported later that the team could see my appendix was very inflamed and also awkwardly placed. So the laparoscopy was abandoned in favour of a normal appendicectomy. I regained consciousness again back in the pre-op room at around 12.30. I was high on morphine; Ben was high in the sky.

I went firmly into convalescent mode. I spent a reasonably comfortable night, resting on my back with my hands over my chest like a sepulchral knight carved on the tombs in Durham cathedral.[note 3]I fancied the knight metaphor. I subsequently discovered, however, that the particular tomb I had in my mind’s eye was that of Joseph Barber Lightfoot in Durham Cathedral. Lightfoot was a 19th century Bishop of Durham.
I wanted to stay as still as possible in order to prevent undue swelling. I still had my operation ‘gown’ on, untied at the back, and was connected to an intravenous drip for fluid and antibiotics. With these impediments, and the fact I had a mask over my face for increased oxygen, I was well able to resist the eager solicitations of the medical staff to get up and be mobile as soon as possible. I did, however, feel like drinking plenty of water and was allowed to have food at dinner time, by which point, detached from my technological supports, I was able to get out of bed and walk around reasonably well. The doctors were impressed with the progress I made after my initial reluctance to move about and I was transferred to a four-bedded unit on a normal ward. My fellow patients were three older men. Two were in for prostate cancer operations and the other had such hardening of the arteries from a lifetime of smoking that his gangrenous leg was due to be amputated the following day. A lesson from hospital, similar to one learned during fieldwork in East Nepal, is that there is always someone with a sorrier tale than you. At least with an appendicectomy, barring unforeseen medical mishap, the prognosis is that one will get better, with all one’s limbs and functional organs untouched.

I was home again after lunch the following day, and found myself signed off work for four weeks to recuperate. I certainly did not feel like straying far from the house until the staples that had been used to secure the various openings in my lower abdomen were removed ten days later. Unlike some appendicitis sufferers, who take pride in being out on the golf course or behind their desks a couple of days after their operations, I was determined to take full advantage of the once-in-a-lifetime opportunity my recovery period offered to stay off work and, I hoped, truly heal. I went into a strangely self-focussed, solipsistic and serene state of convalescence. I was comfortable and had little to do apart from get better. It is hard to explain why, but as a result of the whole episode, I had stopped feeling upset about Ben, and found I had developed a much more philosophical, ‘que sera sera’ mentality about his untoward displacement, his unwelcome excision from our lives. I wrote at the time “It may be that he decides to come back to the UK to live sooner rather than later – but this is no longer ‘wishful thinking’ on my part. Ben is an easy-going and sociable young man, and it may be that Australia is his true metier. If so, I wish him well. I am happy to live for the here and now and enjoy what I have – a beautiful son in the UK, a beautiful son in Australia.”

 

Exegesis

Appendicitis is often regarded in medical terms as an archetypal ‘organic’ pathology. By this is meant a disease like glaucoma or cataracts which is wholly divorced from ‘psychological’ influence. Evidence of this is the way patients with appendicitis have been used as the ‘control’ group in studies of ‘psychosomatic’ disorders (e.g. Bagge 1962). A much voiced anthropological criticism of biomedical practice is that it doesn’t do enough to answer the ‘why me, why now?’ questions that patients are supposed to have about their illnesses. “In trying to identify a cause for the individual’s illness, people closely examine the circumstances and social events of his life before he [sic] fell ill” (Helman 2001: 95). Young refers to these predominantly ‘lay’ interests in ill health as ‘externalizing belief systems’. Such systems focus primarily on the aetiology of the disease, which is commonly believed to arise outside the person’s body, particularly from their social world (Young 1983). In contrast, Young suggests, the medical profession tends to prefer ‘internalizing belief systems’. These concentrate less on aetiology per se and more on physiological and pathological processes to explain why people get sick, largely ignoring the social and psychological correlates preceding the onset of symptoms. Such oversight is partly because of the imperative to ‘do something’ – to use whatever technological means are at one’s disposal to treat symptoms or (ideally) cure the condition - that is at the heart of much medical practice (Barger-Lux & Heaney 1986). Clinicians’ skills must be turned to the pathological crises of the moment, not to idle speculations about the proximate or ultimate causes of particular health problems when such causes are irrelevant to the treatment they can offer. In the case of appendicitis the surgical imperative – to cut it out – is, quite rightly in my opinion, intense. The aetiology of the disease, however, like the appendix itself, remains something of a mystery.

In the case of my appendicitis the ‘why me, why now?’ questions seemed far from irrelevant to me. The metaphorical parallels were obvious, and intense – my own ‘flesh and blood’, a son inherently ‘part of me’ being taken out of my life, while part of my own ‘flesh and blood’ was simultaneously being taken out of my body on the operating table. It seemed incredible that this appendicitis should have occurred on the same day as my son left to start a new life in Australia, and even more extraordinary that the surgeon’s knife should have cut into my abdomen at exactly the same hour as his plane was hurtling down the runway at Heathrow airport. Such a coincidence, were it to be made the subject of a novel or a film, would be dismissed as over-dramatic; but here it was, embedded and embodied in the ongoing narrative of my life, love and loss.

Given the explanatory vacuum in which appendicitis, as an ‘organic pathology’, is lodged in the heads of many members of the medical profession, it is perhaps little wonder that all sorts of ‘external belief systems’ came into my own head to fill the epistemic void. One perspective on my misfortune takes us into the realm of Jung and his theory of synchronicity, the “temporally coincident occurrences of acausal events” (Jung 1992). Jung criticizes our tendency to find expedient, objective causes for coincidences since, he feels, doing so cauterizes the experience and preempts us from exploring the rich inner significance, the ‘symbolic density’, coincidences can otherwise have in our lives (Hogenson 2005). One Jungian psychotherapist (Hopcke 1998) argues for regarding our lives as coherent narratives with synchronistic experiences the key turning points in the plot. The meaning of such private stories and personal symbols can be gleaned only through our subjective interpretation of their significance. In my case, the meaningful event was the onset of appendicitis. Through Jung’s theory, a number of interesting metaphorical associations can be discerned, the ‘symbolic density’ of the appendix deriving from consideration of the role of this mysterious organ in the body, what happens when it becomes diseased, and the synchronic association of my appendicitis with the departure of Ben for Australia.

            In medicine, the appendix is largely viewed as an unnecessary and vestigial organ, an evolutionary relic that may become inflamed and start to fester.[note 4]Recently the suggestion has been made that the appendix may have had a function as a ‘safe house’ for commensal bacteria during our evolutionary past when populations were thinly spread, contact infrequent, and bouts of dysentery or cholera could strip out the harmless bacteria essential for food digestion in a matter of days (Bollinger et al. 2007).
It is tempting, in the circumstances, to draw a metaphorical analogy between the appendix and my relationship with Ben’s mother. We had been married for fifteen years from 1984 and divorced for six when she revealed her antipodean plans. The proposal to remove Ben and the peremptory tearing up of the equal parenting agreement arduously negotiated and agreed through family mediation services meant our relationship became increasingly festering and painful. The English language uses the word ‘appendix’ in other ways too – the appendix of a book or report, for example, the supplements and ‘add-ons’ that are not strictly necessary for the book as a whole to succeed. My bodily appendix was similarly superfluous to the larger text and context of my life – a vestigial organ which, since it was causing me life-endangering problems, was best removed. The treatment I received was, in all respects, excellent. Not for the first time in my life I was thankful to have been living in a country with the health services and welfare systems afforded by 21st century Britain.

In the coda to my hospital treatment, when the surgeon registrar visited my bedside on the morning of my discharge, I asked whether he had any idea why I might have developed appendicitis when I did. His answer to this question was a blunt, straightforward ‘No’. Not for him the concerns of externalising belief systems or Jungian synchronicities when dealing with an organic disease. Nor, I imagine, would such associations be seen as particularly helpful by Susan Sontag who regards the metaphorical associations we make between illness and other aspects of life as counterproductive and unhelpful. In ‘Illness as Metaphor’, she describes the ways in which two of the big killer diseases of the 19th and 20th centuries, TB and cancer, have been regarded as more than just diseases by people in the western world. For her, “the most truthful way of regarding illness - and the healthiest way of being ill - is one most purified of, most resistant to, metaphoric thinking” (Sontag 1978: 3). Brody (1987) rejects Sontag’s argument. While we may share her desire to rid conditions such as cancer of the unthinking, stereotypic and collective associations they may have, on a more individual basis “‘to give disease meaning’ is not something we can choose to do or not to do. We are inevitably involved in the business of attributing meaning to illness whenever we tell stories…or even if we engage in merely medical diagnosis” (Brody 1987: 64). While Sontag derides the metaphorical uses of illness, my experience of the ‘symbolic density’ of appendicitis at that significant point in my life was an overwhelmingly positive one. The operation to remove my diseased appendix (i.e. the appendicectomy) a richly metaphorical ritual event, something which not only provided a timely distraction from the loss of Ben but also, through the polysemic range of metaphorical associations the organ and the circumstances provided, gave me the semantic space to come to terms with, and even recover from, the loss of both.

An appendicectomy might not be the sort of ritual one would wish upon oneself as a marker of one’s son’s emigration ‘down under’. However my death ritual specialist friend had, somewhat arcanely, suggested there was a need for ritual and, as Katz (1981) demonstrates, a hospital operation is an archetypally ritualised event. Some rituals put one into a liminal state in order to emerge as a different person (Turner 1969; 1981).I went in to hospital with a son in one place and an appendix in my body, and came out with my son elsewhere and my appendix in the hospital incinerator. Removal of my infected appendix powerfully symbolized, for me, the changes and loss of relationships. It was a personal somatization, “the cultural patterning of psychological and social disorders into a language of distress of mainly physical symptoms and signs” (Helman 2001: 182). Recovery likewise was of body and mind together, a dual form of healing.

In this anthropological framework, my appendicectomy was a cathartic ritual, the recovery from it, in retrospect, a strong displacement activity to divert me from the emotional trauma caused by the geographic rupture in my relationship with Ben.[note 5]One commentator at the Amsterdam symposium suggested that my appendicitis provided a useful diversion at this time but was fortunately a problem with a beginning and end, akin to breaking a leg. From my perspective, however, a fracture would not have provided the same degree of metaphorical analogy which could be worked into the healing process. It would also, probably, have involved a far longer duration and intensity of pain. Appendicitis and its treatment was truly the best illness/ethnographic experience I could have wished for in the circumstances.
Health, like love, it seemed, was sometimes about ‘letting go’. Whether or not Ben decides to live in the UK again at some point in his future life is no longer the subject of agonising hours of speculation on my part. My appendicitis taught me the importance of living for the here and now, secure in the knowledge that, wherever they both may be, fathers and sons exist under the same ‘sheltering sky’ (Bowles 1949), enjoying a mutual and healthful co-existence irrespective of whether or not they are physically together.

Few clinicians would have time for the personal synchronicity of my appendicitis, the ritual meaning of my appendicectomy, or the autopathography I represent here. All most clinicians will say about the cause of appendicitis, usually, is that it is ‘multifactorial’ (Humes & Simpson 2006). The notion that appendicitis ‘just happens’ is a strong one, and there are doubtless many examples of appendicitis where the onset appears to be random, rapid and completely unrelated to life events – acausal and asynchronous. I would not dispute that, for many people and the doctors who treat them, appendicitis is indeed a disease that happens at random, and, in those terms, my own case can be seen as a simple coincidence, however extraordinary. One set of Australian pathologists did a tongue-in-cheek piece on the supposed association of appendicitis with ingested fruit pips and seeds (Byard, Manton & Burnell 1998). Other physicians such as Creed (1981), however, have drawn associations between appendicitis and life events, and earlier clinicians such as Paulley(1954) have written about the striking narratives of relationship disharmony, love and loss, that seemed to be associated with the disease for some of their patients.

A medical friend with more sympathy for the links between psyche and soma had an explanation that ‘makes sense’ in these terms. Appendicitis, he suggested, is an inflammatory disease and the immune system is infinitely sensitive to personal and environmental cues. It chooses the timing of an illness, when one’s ‘resistance is low’, and when one can (hopefully) take a break from everyday life for some special care and attention. While this is an attractive notion it could in theory have been used to explain almost any illness I might have suffered from at that time, since a failure of the immune system is implicated in many other diseases ranging from the common cold to cancer, as well as appendicitis.[note 6]There is also a reverse stress phenomenon, well documented by GPs, by which people living busy stressful lives often become ill as soon as they have a weekend off or take a holiday, as if the relaxation gives their bodies permission to be ill.
My friend was taking his cue from a less biomedical tradition of speculation and theorisation about the links between illness and life, represented in the self-help literature by writers such as Harrison (1986), Noontil (1994), Hay (2002), and Bourbeau (2004), and in the medical anthropological literature by the idea of somatization, outlined above. All are fairly non-specific in the associations they identify between ‘psyche’ and ‘soma’ and can be accused of perpetuating the myth of ‘just so’ stories, however.

For me, to bowdlerize another classic text in social anthropology, appendicitis was ‘good to think’ (Tambiah 1969, following Levi-Strauss 1964). The worrisome ‘why me, why now?’ questions can never be irrefutably answered and, as long as one is still alive to ask them, are perhaps better addressed by the individual patient than the medical doctor. In this case, I feel the theoretical and methodological tools at my disposal as a medical anthropologist afforded me the opportunity to deal with my illness in ways which might have been more difficult for patients without such a background. The value for me in thinking through the ‘symbolic density’ of my appendicitis and the metaphorical associations the ritual excision of my own ‘flesh and blood’ had for me at such at a sad and difficult time in my life, was the possibility it offered for narrative explanation. Over and above ‘objective causes’ linking (say) my appendicitis with Ben’s departure or the collapse of an Azande granary with witchcraft, narrative explanation offers the ability to “understand events both emotionally and causally at the same time” (Marcum 2008:142).

Illness is a fairly solipsistic moment and, in an autobiographical case study such as this, there are other individuals in the drama whose voices are, inevitably, excluded. My justification in presenting my appendicitis in an autoethnographic format is not to open old wounds. More than an exercise in ‘self-exploration’ (with all the potential criticisms of self-celebration, narcissism and ‘navel-gazing’ to which McLean (2011: 189) alludes), I hope my account, through its reflexivity, transcends ‘self and others’ to offer useful and important insights into appendicitis as an organic pathology and the connections between mind, body and emotion. As McLean (ibid.) puts it:

As we get older and/or experience illness, disability, loss or trauma, our training in ethnography may be a valuable tool for coming to terms with our own decline and losses within the human condition. Our professional training in ongoing reflexive examination of what we experience may prove to be a gift at such times. Being attuned as observers to minute details, to the complexities of social relations, institutions, power and context can help us understand more deeply as we cope with difficult times and circumstances. (McLean 2011: 194)

Engaging with the symbolism and metaphor of this illness episode was far from ‘unhealthy’ in Sontag’s terms. On the contrary, it gave meaning and offered the potential for healing in a situation that could easily be regarded as nothing but the random and cruel concatenation of adverse life events. Although numbers of appendicitis cases have been falling over the past fifty years, Sample (2007) reports 44,562 people in the UK had their appendixes removed during emergency operations in 2006. It would be interesting to know how many of these had an illness narrative of migration, loss, or other significant life events. Appendicitis is not always a disease associated with fractured relationships, displacement and the loss of loved ones but, when it is, thanks to the sophisticated surgical techniques of 21st century medicine, it is at least one that offers the chance of healing, redemption or recovery. Likewise, in a globalizing world, for those who can afford them, new technologies – such as A380 jumbo jets and the internet – offer the chance of physical reunions, or at least virtual reconnections, with those whom migration has perfunctorily excised from one’s life.

 

Notes

Andrew Russell is a Senior Lecturer in the Department of Anthropology at Durham University. A member of the Medical Anthropology Research Group, a fellow of the Wolfson Research Group and a founder member of the transdisciplinary Smoking Interest Group, he does research in the social anthropology of health, illness and public health, particularly tobacco control. He taught social and behavioural sciences to medical students at the University’s Queen’s Campus, Stockton, before he became Director of the University’s Community Outreach and Engagement programme. His book The Social Basis of Medicine (2009, Wiley-Blackwell) won the British Medical Association’s student textbook of the year award in 2010 and in 2011 he was awarded a Higher Education Academy National Teaching Fellowship. E-mail: A.J.Russell@durham.ac.uk.

Earlier drafts of this paper have benefitted enormously from comments, advice and corrections by Jane Macnaughton, Mary Robson, Kathryn Edwards, Louisa McLennan, Iain Edgar, Jill Gordon, Dominic Slowie and Ben Russell. I first presented this material at the Association for Medical Humanities (ANZ) conference ‘Taking heart: A new quest for medical humanities’, in Byron Bay, Australia in June 2006. Participants at the Amsterdam symposium ‘Ethnography and self exploration’ provided further insightful feedback and useful discussion. I am grateful to two anonymous reviewers for their detailed and helpful comments, and for the additional editorial advice and support received. All idiosyncracies and synchronicities expressed in this article remain my own.

  

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