A -rt • ¿- TT' r Surgical History

A Brief History of Appendicitis: Familiar Namesand Interesting Patients

CHRISTIAN J. STRECK, JR., M.D.,* PINCKNEY J. MAXWELL IV, M.D.t

From the *Division of Pédiatrie Surgery and the f Division of Gastrointestinal and Laparoseopic Surgery,Medical University of South Carolina, Charleston, South Carolina

is seen in his work, which was based largely on thedissection of primates.^ However, he did comment onright lower quadrant pain in his wrifing. He noted that"the colic passion, situated in the large bowel, wasfound below the umbilicus, more often on the right, andwas very apt to recur." At that time, surgical treatmentwas often delayed until the last possible moment whenthe abscess was actually "poinfing." Physicians werecareful not to cause discomfort from surgery and toavoid the charge of "having killed the patient byoperation." In fact, the major practice was to allow ei-ther spontaneous abscess drainage with cutaneous fis-tula formation or to allow the patient to die "a peacefuldeath" from sepsis.

C ONSIDERING THE FREQUENCY with which ppceal pathology is diagnosed and treated today, it

is surprising that the term "appendicitis" and the re-commendation for cure by removal of the appendixwere first proposed by Dr. Reginald Heber Fitz (Fig. 1)a mere 125 years ago. This does not however imply thatthe cause of right lower quadrant pain and its appro-priate treatment had not been sought for a long time.From ancient times through the first half of the 19thcentury, almost all inflammatory conditions localized tothe right lower quadrant were mistakenly attributed tothe cecum. As one prominent surgical historian notedin the 1920s, "so many times does it appear that acuteobservers stumbled on the very threshold of the dis-covery that the original lesion in these conditions (of theright iliac fossa) was in the vermiform appendix, that itseems scarcely credible that for less than 45 years havewe had any adequate knowledge of appendicitis." ̂ Thehistory of appendicitis is an excellent anecdote for thehistory of surgery itself. In his presidential address atthe 94th meeting of the Southern Surgical Association,G. Rainey Williams noted that "the history of appen-dicitis includes examples of great resistance to changingconcepts, brilliant but unaccepted early observations,emotional support for unsupportable views, the im-portance of timing, and, finally, the development of ahighly satisfactory solution."^

Ancients

Disease of the appendix is likely as old as man. Oneof the earliest examples, right lower quadrant adhesionssuggestive of previous appendicitis, was discovered inan Egyptian mummy during the Byzantine era. Muchof what was known about human anatomy before theRenaissance was from the second century observationsof Galen. No anatomical description of the appendix

Renaissance

The first descriptions of the appendix can be foundfrom scientists and physicians during the late 15th andearly 16th centuries. Although the anatomic structurewas clearly identified during this period, little wasknown about its function or role in right lower quadrantinflammation. One of the first drawings of the appendixis from Leonardo da Vinci (1492); however, the struc-ture was not described and the drawing was notpublished until the 18th century. Credit for the firstdescription of the anatomic structure of the appendixis given to Berengario Da Carpi (1522), Professor ofSurgery at Pavia and Bologna. In his work, "De HumaniCorporis Fabrica," Andreas Vesahus (1543) illustratedthe appendix (Fig. 2) but called this structure the cecum.He noted this was "because of its true bhnd pouch

Address correspondence and reprint requests to Pinckney J.Maxwell IV, M.D., Assistant Professor of Surgery, Colon and RectalSurgery, Division of Gastrointestinal and Laparoseopic Surgery,Medical University of South Carolina, 25 Courtenay Drive, Suite7100A, Charleston, SC 29425. E-mail: maxwelpj@musc.edu.

FIG. 1. Reginald Heber Fitz, M.D. Reproduced from http://ihm.nlm.nih.gov/images/Bo09136. Accessed October 15, 2012.

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FIG. 2. Colon and appendix, Andreas Vesalius, Di HumaniCorporis Fabrica, 1543. Reproduced from www.appendicitis.pro/the-john-hunter-memorial/the-anatomy-and-physiology.html Ac-cessed October 17, 2012.

nature whereas the actual cecum has three openings."This description led to much confusion in terminologybetween the cecum and appendix for centuries to come.

Age of Enlightenment

During the 18th century, much perturbation regardingthe role of the appendix in right lower quadrant in-flammation and the appropriate treatment for a perfo-rated appendix existed. One of the earliest descriptionsof management of "iliac passion" is from Boerhaave(1709), a leading medical expert of the time. He advisedthe following treatment: large and repeated bloodlet-tings, laxative and cooling clysters (enemas), opiates,and fomentations (warm animal compresses) to theabdomen. Further confusion regarding the etiology ofright lower quadrant abscess formation came fromLorenz Heister (1711) and Mestivier (1759) who bothdescribed perforated appendices resulting from foreignbodies. Claudius Amyand is credited with the firstrecorded appendectomy in 1735. This was performedin an 11-year-old boy with an inguinal hernia. A fecalfistula to the scrotum was found, which resulted froma foreign body perforation of the appendix from a pin.One of the best known surgeons and anatomists of thelate 18th century was Scottish-bom scientist John Hunter.His works and those of other anatomists of the eracontain many descriptions of perforated appendicesor periappendiceal abscesses on pathologic specimens.Surprisingly, there was still no recognition of the appendix

as the primary cause of right lower quadrant inflam-mation by Hunter and colleagues.

19th Century

In the early 19th century, there was continued con-fusion regarding the etiology of right lower quadrantpain. Baron Guillaume Dupuytren, a leading surgeonof Hotel Dieu in Paris, felt that right lower quadrantinflammation began from cecal pathology. In regard tohis behefs, he famously said: "I have been mistaken, butI have been mistaken less than other surgeons." Manyother papers of the period further complicated the issue.Another leading source on the topic was Goldbeck'sgraduation thesis (1830) on "Inflammation in the RightIliac Fossa," which described accurately all of the signsand symptoms of appendicitis. Like Dupuytren, hemistakenly believed right lower quadrant pathologyoriginated from cecal mucosal inflammation, a processwhich he named "perityphlitis."

Despite confusion regarding the etiology of appen-dicitis, one of the greatest advancements in manage-ment occurred in 1848. Under chloroform anesthesia,Hancock performed the first deliberate laparotomyto drain a periappendiceal abscess before "pointing"or fluctuation. Four additional cases were reported byWillard Parker in 1867. At this time, he advocated sur-gical drainage after the fifth day of illness but withoutwaiting for fluctuance, an approach that was later creditedwith reducing mortality from perforated appendicitis.

Two of the greatest advances in the management ofsurgical patients, although not specific to the historyof appendicitis, occuiTed in the mid-19th century. Thefirst of these was the development of general anes-thesia. In 1846, William T. G. Morton, a Boston den-tist, persuaded John Collins Warren, a surgeon at theMassachusetts General Hospital, to allow him to ad-minister ether during the removal of a small vasculartumor of the neck. After successful surgery. Warren,impressed with the new discovery of inhalational an-esthesia, famously stated "Gendemen, this is no hum-bug." The second major advance came in the field ofinfectious disease. Despite the previous work of IgnazSemmelweis, demonstrating the importance of hand-washing in obstetrical clinics, most surgery was practicedunder unsanitary conditions where bloody laboratorycoats were seen as a sign of the surgeon's experience.Based on the work of Louis Pasteur demonstratingthe role of micro-organisms in infection, Joseph Listerbegan to experiment with carbolic acid solution onhands, surgical instruments, and wounds. In 1867, Listerpublished his first series of papers on antisepsis in TheLancet and dedicated his career to improved methodsof antisepsis, which greatly advanced the safety ofsurgery.

No. 2 A BRIEF HISTORY OF APPENDICITIS Streck and Maxwell 107

One of the greatest contributions to the managementof appendicitis came not from a surgeon, but rather apathologist. In June 1886, the first meedng of the As-sociadon of American Physicians was held in Wash-ington, DC, with many of the leading physicians present,including Dr. Sir William Osier. At this meeting, Regi-nald Heber Fitz, a Harvard pathologist, presented hispaper entitled "Perforating Inflammation of the Vermi-form Appendix; with Special Reference to Its EarlyDiagnosis and Treatment." In this paper, Fitz empha-sized that the etiology of most right lower quadrantinflammatory disease was the appendix. He provideda clear description of the chnical features of appendicealdisease, described in detail the pathological changes,and coined the term "appendicitis." Most importantly,he advocated early surgical removal to the audience andended any further challenge to the appendix as the causeof right lower quadrant inflammatory disease.

Not long after this meeting, Thomas Morton (1887)was credited with the first successful operation de-liberately performed for appendicitis. This is based ona case report, which he presented to the College ofPhysicians on June 1, 1887. The case was of a 26-year-old man managed medically (calomel, soda water, pepsin,stimulants, quinine, poultices [warm compresses], andeventually leeches) over the course of a week whenhe eventually was taken for laparotomy with drainage ofan intra-abdominal abscess and appendectomy withabdominal inigation. He recovered over the next severalweeks successfully. Interestingly, Morton presentedanother similar case of a woman who underwent appen-dectomy several months prior who died 3 hours post-operatively from septic shock. In answer to Dr. Morton'sdiscussion as to the advisability of removing the humanappendix. Dr. Chapman replied: "a true vermiform ap-pendix is found only in six animals: man, gorilla, chim-panzee, orang, gibbon and wombat. There can be nodoubt, therefore, that the cecal appendix is one of thoseparts of the human body having no particular function ofsignificance, being of use only in animals... In the hu-man being it ought to be removed with no bad effectwhatsoever, so that I thoroughly agree with Dr. Mortonin what he has to say regarding the opening of the ab-domen and taking out the appendix. It seems to me thatthe human being is better off without the appendix thanwith it, for it is nothing but a trap to catch cherry stonesand other foreign bodies."^^ Interestingly, Dr. Morton'sbrother and son both died of acute appendicitis.

Two significant advances in the diagnosis andtreatment of appendicitis are attributed to Dr. CharlesMcBurney (Fig. 3) who practiced in the RooseveltHospital in New York. In 1889, McBumey described thepattern of migratory pain with eventual point localiza-tion one-third of the distance between the anterosuperioriliac spine and the umbilicus, "McBurney's Point.'"^

Later, in July of 1894, he described the lateral muscle-splitting incision in Annals of Surgery. Interestingly,Dr. Lewis McArthur was to have described the sameincision to the Chicago Medical Society the previousmonth. His paper was postponed when the programran overtime and the term "McBurney incision" haslasted the test of time. Further modiflcation of the rightlower quadrant incision occurred over the subsequentdecade. Drs. A. E. Rockey of Portland, Oregon, andGwilym G. Davis of Philadelphia are credited with theprominence of the transverse right lower quadrant skinincision with division of the underlying muscle layersalong their fibers.

One of the most interesting anecdotes regarding ap-pendicitis involves a surgeon as a patient. In earlySeptember 1897, Dr. Harvey Cushing (Fig. 4), a surgeryresident at Johns Hopkins, operated on a patient witha perforated appendicitis who subsequently died ofsepsis. Several weeks later, he developed abdominalpain causing a great deal of personal apprehension.As his symptoms progressed, he subsequently had toconvince Dr. Halsted to operate despite the objections ofDr. Osier. He was finally taken to the operating roomthe next day. During bis hospital course. Dr. Cushingdocumented his own history and physical examinationand it was said that he would have assisted on his ownoperation had it been possible.

20th Century

Two of the most famous cases of patients with ap-pendicitis occurred during the next decade. Around

FIG. 3. Charles McBurney, M.D. Reproduced from http://en.wikipedia.org/wiki/Charles_McBurney_(surgeon). AccessedOctober 15, 2012.

FIG. 4. Harvey Cushing, M.D. Reproduced from www.histansoc.org.uk/uploads/9/5/5/2/9552670/7753552.jpg'? 161. Accessed October15, 2012.

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FIG. 5. Major Walter Reed, M.D. Reproduced from http://en.wikipedia.org/wikiAValter_Reed. Accessed October 15, 2012.

FIG. 6. Coronation portrait, King Edward VII. Reproducedfrom http://en.wikipedia.org/wiki/Edward_VII. Accessed October15, 2012.

1900, U.S. Army physician Dr. Walter Reed (Fig. 5)demonstrated that the mosquito was the vector of thevirus causing yellow fever. He both demonstrateddisease transmission from mosquitos and disprovedthe common belief that yellow fever could be trans-mitted through soiled clothing, articles that becameknown as fomites. Research on yellow fever underDr. Reed's leadership allowed the completion of thePanama Canal between 1904 and 1914. Unfortunately,Dr. Reed was unable to see the benefit of his great work.He developed appendicitis in 1902 and initially declinedsurgery. After evidence of perforation, he eventuallyunderwent surgery and later died from a fecal fistula andsepsis.

Perhaps the most famous patient with appendicitiswas the U.K.'s Prince Albert Edward, heir to the throneof Queen Victoria. After Victoria's death in January1901, Edward developed abdominal pain 12 days beforehis scheduled coronation. He subsequently developedan abscess when his appendix ruptured but planned tocontinue with the scheduled coronation anyway. Tendays after the onset of symptoms, and a mere two daysbefore the scheduled coronation, he finally allowed

Sir Fredrick Trêves, with the support of Lord Lister, todrain his appendiceal abscess and postpone the coro-nation by six weeks (Eig. 6). When Edward was hesitantto delay the accession. Trêves was famously quoted"Then Sir, you will go as a corpse." After the operation.Trêves was said to have spent seven sleepless nights atthe bedside. The day after surgery, Edward was reportedto be up from bed and smoking a cigar. Two weeks later,Edward was declared free from danger and appendicealsurgery entered the mainstream of medical practice.Dr. Trêves went on to become one of the busiest sur-geons in London. Ironically, his daughter later died fromcomplications of appendicitis.

During the early 20th century, great progress wasmade in the management of appendicitis. The impor-tance of fluid resuscitation was recognized makingsurgery significantly safer. In addition, the value ofoperating before peritoneal contamination from rup-ture helped greatly in reducing mortality. Einally, thedevelopment of antibiotic therapy in the 1940s furtherreduced morbidity and mortality from appendicitis.Today, appendectomy is one of the most common ab-dominal operations performed with excellent outcomesfor acute appendicitis.

Considering the frequency with which appendicitisis diagnosed and treated today, one might assume thatthe etiology of the disease has been known since anti-quity. In reality, the cause and treatment of appendicitishave only been known for the past 125 years. Rec-ognition of the pathology of right lower quadrant in-flammation by Dr. Reginald Eitz and new developmentsin antisepsis, anesthesia, and surgical techniques in thelate 19th century, and later the development of antibiotictherapy, paved the way for the improved surgical out-comes after appendectomy, which are seen today.

REFERENCES

1. Deaver JB. A Treatise on Appendicitis. Philadelphia, PA:P. Blakiston, Son & Co.; 1896.

2. Williams GR. Presidential Address: a history of appendicitis.With anecdotes illustrating its importance. Ann Surg 1983;197:495-506.

3. McCarty AC. History of Appendicitis Vermiformis. Its Dis-eases and Treatment. Presented to the Innominate Society, Univer-sity of Louisville, Louisville, KY; 1927.

4. Powell JL. Anecdotes on appendicitis: Charles McBurney,MD (1845-1913). J Pelvic Surg 2001;7:39-41.

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