Appendicitis at 100

On Sunday, January 17,1886, a 24-year-old Boston woman experienced searing, excruciating pain in her right lower abdomen. Her doctor prescribed applications of moist heat to her abdomen, an enema of warm water, and a dose of morphine, all to be repeated “as needed.” Two days later, the pain had subsided, but, by afternoon, it returned, this time afflicting the entire abdomen. The doctor increased the dosage of morphine, and the pain again let up. Over the next two days, the woman’s pulse ranged between 88 and 96, and her temperature hovered between 99 and 100 degrees. On Thursday, she was given castor oil and began to vomit. Vomiting continued the next day and her abdomen swelled. Her doctor—and two consultants who had been called in—now administered citrate of magnesia, calomel, and jalap—all purgatives—and an enema. On Saturday morning her pulse of 140 became almost imperceptible; her abdominal swelling increased, and her extremities went cold. Violent vomiting began again, and she died at 12:30 P.M.

This woman’s case appeared in the Boston Medical and Surgical Journal in 1886. As it happened, there also appeared in the very same issue an extract of a study done by a Dr. Reginald Fitz of Boston—a study that solved the riddle of appendicitis for once and for all. Deaths like the one described above, until then a common occurrence, would begin to become a rarity. In his landmark paper, Fitz not only defined the nature of the disease but also described its proper diagnosis and treatment. Today, 300,000 potentially life-saving appendectomies are performed each year in America, and Fitz’s work a century ago paved the way.

The appendix and its inflammation took thousands of years to be understood. Coptic jars, in which Egyptian mummies’ intestines were placed, sometimes carried an inscription referring to the “worm of the bowel,” but no definitive description of the organ existed until 1492, when Leonardo da Vinci described and drew it. In 1710 the Flemish anatomist Phillippe Verheyen gave the organ its name, appendix vermiformis . Most of us, of course, simply say appendix .

The appendix is a sort of wormlike finger that protrudes from the cecum, the portion of the large intestine located in the right lower abdomen. It usually runs three or so inches in length, but may exceed ten or more, and has a diameter of about one-third of an inch. A narrow passageway, the lumen, extends down the inside of the appendix beginning at the opening to the cecum, where there is a fold of mucous membrane called Gerlach’s valve. What purpose this equipment may once have served is unknown. Most consider the entire structure vestigial, but it may once have aided in the digestion of cellulose.

Trouble arises when an obstruction at or near Gerlach’s valve inhibits the flow of appendiceal mucus out into the cecum. Pressure inside the lumen then becomes elevated, squeezing the appendix walls and the blood vessels therein. Thus distressed, the appendix can fall prey to the myriad luminal bacteria, the result being inflammation—appendicitis. Without treatment the inflammation typically leads to gangrene and perforation and the escape of lethal fecal material into the abdominal cavity. The result is peritonitis and sometimes death. The obstruction may be caused by foreign bodies, such as bones, seeds, pits, pins, screws, tacks, teeth, parasites and even bubble gum, but perhaps the most common culprits are swollen appendiceal lymph tissue and fecaliths—hardened feces. Normally feces are held at bay by Gerlach’s valve, but when they do enter the appendix they dry up and therefore cannot escape.

The disease began to be pinpointed in the early nineteenth century. In 1812, the British doctor James Parkinson reported that a five-year-old boy had died of a diseased appendix following two days of illness. In 1813, a German pathologist named Wegeler reported a case in which “the cecum was destroyed by gangrene, having its starting point in the vermiform appendix, in which organ were several stones.” In 1839, the English physicians Thomas Addison and Richard Bright wrote, “From numerous dissections it proved that the fecal abscess thus formed in the lower right side arises, in a large majority of cases, from the disease set up in the appendix.” The first surgery involving a diseased appendix was performed by the English surgeon Henry Hancock in 1848, and in 1884, a doctor in Zurich “cut off in toto” the appendix of a stricken 17-year-old boy. The boy died, but his case was apparently the first in which the disease was diagnosed and the organ then removed.

The first reported clear case in the United States of what we now call appendicitis occurred in 1815. A 40-year-old sea captain named Parker Robert was stricken by an “obtuse, deep seated pain in the right side of the abdomen,” according to his doctor, Oliver Prescott. Prescott perceived that the trouble was in the cecum and prescribed a brew of calomel, aloes, senna, gambier, niter, potassium subcarbonate, opium, and hyoscyamus. Within five days, the captain died. An autopsy disclosed a cocoa bean at the entrance to his appendix, and Prescott recognized this as “unquestionably the immediate cause of our patient’s death.”

Though Prescott was clearly in the dangerous dark ages relative to the management of the captain’s disease, he knew no less than the physicians who treated the woman in Boston 71 years later. There were intervening sparks of enlightenment, but they all failed to throw permanent light on the problem until Reginald Fitz came along.

Reginald Heber Fitz was born on May 5, 1843, in Chelsea, Massachusetts. After receiving his M.D. from Harvard in 1868, he studied for two years, first in Vienna and then in Germany under Rudolf Virchow, generally regarded as the father of pathology. Returning to Boston in 1870, Fitz received appointments as a microscopist at the Massachusetts General Hospital and as an instructor in pathological anatomy at Harvard Medical School. He rose quickly at Harvard, becoming assistant professor in 1873 and Shattuck Professor of Pathological Anatomy in 1879.

A student recollected, “His lectures were terse, vigorous, lucid and models of flawless didactic exposition, and in clinical exercises his cross-examination method and keen forensic style were as illuminating as they were stimulating. …” According to a colleague, Fitz was “not an investigator in the sense that he carried out or led original, experimental research,” yet his “penetrating clearness of vision … enabled him to extract, as could no one else, from a mass of apparently unrelated observations, the concise, clear clinical picture.”

Fitz’s pathbreaking paper, entitled “Perforating Inflammation of the Vermiform Appendix; With Special Reference to Its Early Diagnosis and Treatment,” was read before the Association of American Physicians, June 18,1886 and was published in the American Journal of the Medical Sciences the following October. It contained a meticulous point-by-point analysis of 466 cases of abdominal disorders that had previously been variously diagnosed and showed that they all involved a diseased appendix. Moreover, Fitz demonstrated that the disease always started at the appendix. He wrote that “variations in length, position and patency [of the appendix], whether congenital or acquired, are of obvious importance in explaining many of the apparent differences in the clinical histories.” Being an astute clinician, Fitz went on to set forth simple and effective methods both of diagnosis and of treatment, and he concluded his monumental study with three fundamental statements: the early recognition of appendicitis is of vital importance; its diagnosis is usually not difficult; and its treatment by appendectomy is generally indispensable.

Another truly important thing Fitz did in his paper was to introduce the term appendicitis . Some two dozen names had previously been used for what had been thought to be a variety of diseases. The new, single name would help eliminate this confusion. Some years later he commented, “The word was coined by me purely for practical purposes. I wished to call attention to inflammation of the vermiform appendix as … that to which treatment was directly to be applied. … The subject is now so well understood that its nomenclature seems of minor importance … but I much prefer appendicitis to Fitz’ disease.”

Many considered appendicitis a clumsy or “barbarous” word, and some suggested substitutes, such as apophysitis and scolecoiditis . Not a few physicians, especially in remoter areas of the country, began to believe there were now two distinct diseases that afflicted the right iliac fossa—typhlitis (a prevalent older term) and appendicitis. For a number of years to come, typhlitis, perityphlitis, and even “stoppage of the bowels” would continue to be used alongside appendicitis.

Nevertheless, 1886 remained the year of conquest—the “year of appendicitis.” As Howard Kelly, a surgeon and member of the first medical faculty at Johns Hopkins, aptly put it, “Now everything was to be changed and as a tangled skein full of knots and false clues yields at once to the hand which holds the right thread, so the perplexities, obstacles, and unfounded notions which hitherto blocked the way, disappeared as soon as Fitz’ paper supplied and enforced the acceptance of the correct fundamental fact—that the multifarious abdominal disorders hitherto variously named were all no more than forms and stages of inflammation of the appendix.”

To some extent this classic paper was a reaffirmation of the views of many earlier investigators, some of whom were as perspicacious and articulate as Fitz. However, by 1886, the time was ripe for the medical profession to focus on appendicitis and to develop the operation to combat it. And Fitz was the right man to spark the change. He was a pathologist, not a surgeon, and thus could command respect in both of these then sometimes uncooperative fields.

Who did the first appendectomy?  The patient in Zurich in 1884 had died. In 1886, Richard Hall, a New York surgeon, removed an appendix and the patient lived. But Hall had diagnosed the case as “strangulated hernia.” In 1887, Thomas Morton, a prominent Philadelphia surgeon, became the unchallenged first to deliberately and successfully operate for and remove an inflamed ruptured appendix after having made the correct diagnosis. Less than a year later, he was the first to diagnose and remove an inflamed appendix that had not yet ruptured. His interest in the operation may have been more than clinical. His brother and son both died of appendicitis.

Morton’s accomplishments initiated a period of quickened interest in Fitz’s revelations, and scores of skilled and famous surgeons now began making major contributions. In 1889, Charles McBurney, a New York surgeon, published a paper in which he pinpointed the tenderness and pain associated with appendicitis at a point one and a half to two inches from the protuberance of the right hip in the direction of the navel. John Deaver, a turn-of-the-century pioneer in abdominal surgery, considered this the greatest of all advances in the diagnosis of appendicitis, “not so much because the pain is in every case just at the spot, but because it put into the physicians’ and surgeons’ thoughts, in a practical concrete way, a ready method of excluding nearly every other disease with almost certainty.” With that aid to diagnosis, a real psycho- logical barrier had been removed and the number of surgeons willing to amputate the appendix increased by leaps and bounds. And with practice came the development of standard techniques.

The value of swift action was confirmed by the experience of a surgeon named John Murphy. By 1894, he had performed 108 operations with a loss of 10 lives, an astonishing success rate, considering that the majority of the cases had not been seen until rupture. The secret to preventing infection, as Murphy put it, was, “Get in quick and get out quicker.”

Further advances included discovery of the salutary effect of raising the head of the peritonitis patient’s bed eighteen inches or so, to facilitate the gravitational flow of fluids in the least dangerous direction; withholding all food before operating to keep the intestines inactive; and avoidance of laxatives and cathartics. For all intents and purposes, basic surgical procedures had all been established by the early years of the twentieth century. Between 1925 and 1955, the mortality rate for the operation decreased from 14 percent to one-tenth of one percent. Innovations during this period included, in approximate order of their introduction, improved anesthesia, nasogastric suction, blood transfusions, intravenous fluids, penicillin, and broad-spectrum antibiotics.

Today the treatment of simple, acute appendicitis—when the trouble has not progressed beyond the confines of the appendix—is one of the safest surgical procedures and one in which there is no disagreement among the surgeons except concerning such fine points as the type of incision to make or what to do with the “stump.” A perforated, ruptured appendix, though, remains an emergency. It still can kill.

Fitz and the appendectomy helped put the United States on the road to becoming the world leader in surgery. By the turn of the century America was well ahead of Europe and Great Britain in abdominal surgery. The uncrowned king of England and his personal physicians brought this point home in 1902, when Edward VII was felled by “perityphlitis,” as stated in the official announcement from Buckingham Palace. Edward had been sick for several weeks and was taking laxatives all the while. After his appendix ruptured, he was finally operated on, just three days before his coronation. He lived to assume the throne, and only then did the appendectomy become widely accepted in Britain.

The king was subsequently accused by some of making the appendectomy a new medical fashion. If he did so, he was just following in the footsteps of Fitz.