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Historical aspects of appendicitis in children James K. Hamill,*† Andrew Liley‡ and Andrew G. Hill† *Paediatric Surgery Services, Starship Children’s Hospital, Auckland, New Zealand †Department of Surgery, University of Auckland, Auckland, New Zealand and ‡Department of Paediatric Anaesthesia, Starship Children’s Hospital, Auckland, New Zealand
Key words appendicectomy, appendicitis, appendix, history, post-operative pain. Corrrespondence Dr James K. Hamill, Paediatric Surgery Services, Starship Children’s Hospital, Private Bag 92024, Auckland 1142, New Zealand. Email: [email protected]
Abstract Evidence of appendicitis exists from ancient Egyptian mummies but the appendix was not discovered as an anatomical entity until the renaissance in Western European literature. Much confusion reigned over the cause of right iliac fossa inflammatory disease until the late 19th century, when the appendix was recognized as the cause of the great majority of cases. Coining the term ‘appendicitis’ and making the case for early surgery, Fitz in 1886 set the scene for recovery from appendicitis through operative intervention.
Accepted for publication 10 September 2013. doi: 10.1111/ans.12425
Felix qui potuit rerum cognoscere causas He who has been able to learn the causes of things is happy Virgil. Georgics, 29 BC.1
Introduction The lifetime risk of appendicitis is around 7–9%2 and appendicectomy is one of the most common emergency operations in children. Mortality from appendicitis in children has been recently estimated at 0.01% (non-perforated disease) to 0.06% (perforated appendicitis).3 Surviving appendicitis with complete recovery is now expected but was not always so. Author Roald Dahl was 3 years old when his 7-year-old sister, Astri, died from the disease; it was 1920. Five years later, his half-sister, Ellen, contracted appendicitis but recovered after having her appendix removed, ‘on our own nursery table at home by the local doctor and his anaesthetist.’4 Early surgery revolutionized recovery from appendicitis. Since Fitz’s seminal paper in 1886, surgeons have followed the policy of urgent appendicectomy; however, some investigators now challenge this approach. Conservative treatment of complicated appendicitis is an accepted option5,6 and the place of interval appendicectomy after conservative treatment is under investigation.7,8 On the other hand, enhanced recovery from operative treatment may soon allow routine outpatient surgery for acute appendicitis.9,10 In the light of contemporary debates, a review of the history of appendicitis is timely. In this paper, we recount the discovery of the appendix and appendicitis, from ancient Egypt, through Europe, ending in America in the late 19th century. © 2013 Royal Australasian College of Surgeons
Early history Ancient Egyptians placed the bandaged viscera of the deceased in canopic jars prior to mummification. Collins in his article, Historic Phases of Appendicitis described the inscriptions found on certain jars referring to the ‘worm’ of the bowel.11 G. Elliot Smith discovered the mummified body of a young Egyptian woman ‘in which a thick band of old “adhesion” springs from the appendix near its tip and passes over to be attached to the other side of the pelvis. It seems to be clear evidence of old appendicitis.’12 Hippocrates said, ‘From the rupture of an internal abscess, prostration of strength, vomiting, and deliquium animi result’, and ‘Suppuration upon a protracted pain of the parts about the bowels is bad.’13 Some of Hippocrates’ patients would have had appendix abscesses. Celsus (probably around the time of Christ) wrote, ‘The disease which is in the larger intestine is situated chiefly in that part which I have described as a blind alley. There is extreme flatulence, violent pains especially on the right side . . .’14 Zachary Cope in his A History of the Acute Abdomen suggests the ‘blind alley’ refers almost certainly to the caecum and appendix and the disease described could do very well for appendicitis.15 Aretæus of Cappadocia (30 AD) wrote, ‘I have myself made an incision into an abscess of the colon on the right side, near the liver, when a large quantity of pus escaped, which flowed also several days through the kidneys and bladder, and the patient recovered.’16 Collins suggests that Aretæsus had drained an appendix abscess.11 No mention of the appendix is found in the works of Aristotle (4th century BC) nor Galen (2nd century AD).11 Both based their ANZ J Surg 84 (2014) 307–310
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anatomical discoveries on vivisection: Galen dissected pigs and the Barbary macaque; neither have an appendix.17 From this time postmortem examinations were frowned upon or forbidden15 so the works of Aristotle and Galen formed the foundation of anatomical knowledge until the renaissance.
The appendix discovered The first definite documentation of the appendix in Western European literature appeared in the renaissance. Leonardo da Vinci sketched an appendix in 1492.18 Berengario da Carpi formulated the first written description of the appendix in 1521,19,20 describing an ‘additamentum . . . empty within, and in breadth less than the smallest finger of the hand, and of a length of three inches or thereabouts.’21 Andreas Vesalius, professor of anatomy at Padua, illustrated and described the appendix in 1543, calling it ‘cæcum’ meaning blind pouch.11,22
Appendicitis discovered Jean Fernel, the French physician, mathematician and philosopher,23,24 may have made the first description of appendicitis. Morer in his History of Appendicitis translates Fernel’s 1544 account: ‘At the opening of the cadaver, we find the caecum squeezed and contracted . . . resulting in acrid and corroding material being prevented from moving on, stagnating for an unusually long time, it opening a way into the abdominal cavity, the intestine being red and perforated a short distance from the obstruction . . .’25 What of the ‘squeezed caecum’ – was Fernel using Versalius’ terminology for the appendix, and could this have been ileus in perforated appendicitis? November 1711, in the amphitheatre of the town Altdorf bei Nürnberg in Germany, Lorenz Heister, anatomist, surgeon and botanist, performed a public dissection of the body of a malefactor. Forty-two years later (1753) Heister wrote, ‘Wanting to demonstrate to the spectators the true position of the large intestine, I found the vermiform appendix of the caecum a black colour, contrary to what is natural, and more adherent than normal to the membrane of the ventral abdominal wall (called peritoneum). Wanting to isolate it by gentle traction, the tissues of the vermiform appendix tore apart, despite the cadaver being very fresh, and two or three spoonful of pus came out. This can serve as proof that in the caecum and the vermiform appendix there can exist inflammation and abscess.’26
First appendicectomy Ever since infancy, 11-year-old HanvilAnderson had a scrotal hernia. For the last month ‘a great quantity of an unkindly sort of matter’ had been discharging from a fistula at the base of the scrotum.27 In December 1735, Claudius Amyand operated on the young lad. Finding a contracted, inflamed appendix perforated by ‘a pin incrusted with stone towards the head’ he applied a ligature and performed history’s first appendicectomy.27 Amyand wrote, ‘Tis easy to conceive that this operation was as painful to the patient as laborious to me.’27 Young Hanvil recovered after a hospital stay of about a month.27 The appendicectomy by Amyand is remarkable for several reasons. It is the first recorded appendicectomy. The patient was a child. The incision via a hernia is germane in the light of modern innovative approaches, natural orifice surgery28 and single incision
Hamill et al.
laparoscopic surgery.29 Finally, it is a story of recovery following surgery, albeit slow and painful.
A fatal illness Over the subsequent century a series of post-mortems were described. Mestivier of Saint André hospital, Bordeaux performed the autopsy of a 45-year-old man after the chief surgeon had drained about a pint of pus from an abscess to the right of the umbilicus (1757). Mesivier found a pin had perforated the appendix, causing gangrenous appendicitis.30 Zachary Cope reported that John Hunter described a gangrenous appendix at the autopsy of Colonel Campbell Dalrymple.15 John Parkinson, the London surgeon who described the eponymous ‘shaking palsy’, reported a gangrenous appendix with a fecolith at the autopsy of a 5-year-old boy.31 Jean-Baptiste Louyer-Villermay described two men ‘in the strength of youth, endowed with good constitution, struck without warning, at a time of perfect health, by a most acute inflammation . . . But how can an inflammation of an organ of such small volume, and especially of such limited importance, cause such a rapid death . . .?’32 François Mêlier reported eight autopsies with appendiceal obstructions, included a 13-year-old boy with an appendix full of roundworms, and an 18-year-old adolescent with a gangrenous appendix containing several fecoliths (‘calculs’).33 Mêlier wrote, ‘If it was in fact possible to establish, in a manner certain, positive, the diagnosis of these afflictions, and that they were always well defined, one could conceive the possibility of relieving the disease, by means of an operation: we will arrive perhaps one day at this result.’33 Mêlier’s prediction would await the advent of anaesthesia and antisepsis before fulfilment. Vayre and Hillemand, in their 2007 article on Mélier,34 noted that despite such ‘reasonable analysis’Mélier’s ‘innovative idea’ was opposed by Grisolles, professor of medicine (in his 1848 Traité élémentaire et pratique de pathologie interne35) and Mélier’s own professor of surgery, Guillaume Dupuytren.36
Confusing the caecum The eccentric Dupuytren, Chief Surgeon at Paris’ Hôtel Dieu 1815– 1835, once said, ‘I have been mistaken, but I have been mistaken less than other surgeons.’37 In describing a fatal case of appendicitis in a young man be wrote, ‘These inflammations, maladies of the appendix, of which I have seen quite a large number of examples, have barely reached the attention of authors, and we owe to one of my students, M. le docteur Melier, an excellent work on the lessons of this organ.’36 In his Lectures on Clinical Surgery (published posthumously in 1939), Dupuytren described seven cases of iliac fossa abscess, six on the right, but assigned the propensity for sepsis on this side to the anatomical arrangement of the caecum, not the presence of the appendix in the right iliac fossa.36 The caecum’s retroperitoneal nature, junction with the small bowel and narrow ileocaecal valve, he believed, predisposed foreign bodies to lodge, leading to abscess formation.36 One wonders whether Dupuytren was influenced by Fernel’s case of caecal stricture and bowel obstruction described 300 years earlier. On the other hand, Dupuytren did advise his students, ‘read little, see much, do much’ (‘peu lire, beaucoup voir, beaucoup faire’).37 © 2013 Royal Australasian College of Surgeons
Historical aspects of appendicitis
Husson and Dance, Dupuytren’s colleagues at the Hôtel Dieu, described 15 cases of right iliac fossa abscess without once mentioning the appendix.38 Menière, also of the Hôtel Dieu, described two boys aged 16 and 18 years with right iliac fossa inflammatory ‘tumours’. Both recovered completely after hospital stays of 12 days and one month, respectively. Menière noted ‘the prognosis is not in general very bad, since in 16 cases observed . . . one sole individual succumbed.’ He described three clinical courses: (i) rapid improvement in symptoms with resolution of the inflammatory mass; (ii) fluctuant abscess with evacuation of pus per anus and recovery; (iii) general peritonitis with a guarded prognosis.39 Clearly, recovery without surgery was possible even before the days of antibiotics, and can be seen as an historical basis contemporary management practices such as the non-operative management of an appendix mass. Gottfried Goldbeck, a student at the University of Giessen, read Husson and Dance’s paper, and on the advice of his teacher, Professor Puchelt, Goldbeck wrote his M.D. thesis on Inflammation in the Right Iliac Fossa. In it he relates a story (as recounted by Zachary Cope): ‘A boy aged ten had eaten a lot of cherries together with their stones; soon after eating them he fell from a wagon and after about eight days presented the following symptoms of disease. He was in a feverish condition, complained of constipation and a definite pain in the right iliac region which felt distended, rigid, and tender with painful spasms on urination. These symptoms were accompanied by an attack of ileus . . . All treatment was of no avail and the patient died. The post-mortem showed the following: The caecum was quite filled with faeces and cherry stones and was in a gangrenous condition. The neighbouring part of the peritoneum and the bladder were inflamed. In the blind end of the vermiform process there was a cherry stone impacted in the neighbourhood of which the wall of the process was distended, gangrenous and perforated and surrounded by a collection of pus.’15 Despite so clearly describing perforated appendicitis, Goldbeck concludes his thesis, ‘I therefore venture to propose the designation “Perityphlitis” for this disease . . .’15 emphasizing the caecum (Gk, τυφλος, typhlos, blind). Why were these authors preoccupied with the caecum but ‘blind’ to the appendix? Morer in his History of Appendicitis25 suggests the answer may lie in Richerand’s 1805 textbook of surgical pathology: ‘We give the name abscess to all collections of pus formed in soft tissue . . . we do not use the name abscess for collections of purulent fluid in serous cavities of the meninges, pleura, peritoneum or synovia.’40 The retroperitoneal caecum, understood to be in contact with the soft tissues of the iliac fossa, thus could form pus, but the appendix, surrounded by peritoneum, apparently could not.
Solving the riddle Around the first half of the 19th century, several authors recognized appendiceal inflammation. James Copland, in his Dictionary of Practical Medicine wrote of inflammation of the caecum, ‘There are few diseases more defined in their character . . . It may attack the vermiform appendix only, or the cellular tissue connecting the cæcum to the internal iliac muscle.’41 Thomas Hodgkin (discoverer of Hodgkin disease) stated in his Lectures, ‘inflammation of the peritoneum, in the Iliac fossa, is sometimes set up by disease in the Appendix cæci.’42 Hodgkin describes three degrees of inflammation: (i) ‘very limited’; © 2013 Royal Australasian College of Surgeons
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(ii) perforated but limited to the right iliac fossa; (iii) diffuse, which ‘quickly proves fatal’.42 Richard Bright and Thomas Addison of Guy’s Hospital in their 1839 publication, Inflammation of the Cæcum and Appendix Vermiformis stated, ‘from numerous dissections it is proved that the fæcal abscess thus formed in the right iliac region arises, in a large majority of cases, from disease set up in the appendix cæci.43 It is found that this organ is very subject to inflammation, to ulceration, and even to gangrene.’43 Émile Leudet in Researches Anatomical, Pathological and Clinical on Ulceration and Perforation of the Vermiform Appendix stated, ‘the appendix ileo-cæcal is in effect a quite frequent cause of localised inflammation . . . perforation of the appendix ileo-cæcal is, of all the parts of the intestine, the one observed perhaps the most frequently.’44 Leudet reviewed 30 of his own observations including three boys (aged 8, 16 and 17 years) who succumbed to appendicitis.44 Leudet was ahead of his time, since it would be another 27 years before appendiceal inflammation was widely accepted by the surgical community. In June 1886, Harvard professor Reginald Fitz read a paper titled, Perforating Inflammation of the Vermiform Appendix, before the first meeting of the Association of American Physicians.45 Fitz analysed 257 cases and reviewed the literature. He stated, ‘it seems preferable to use the term appendicitis to express the primary condition.’46 Despite the word mixing a Latin word (appendere, to hang upon) with a Greek suffix (-itis, pertaining to) ‘appendicitis’ entered the parlance of surgeons and achieved universal recognition. Osler referred to the meeting as ‘the coming of age party of clinical medicine in America.’45 Abel credits Fitz with ‘solving of the riddle of appendicitis.’47 Fitz acknowledged spontaneous recovery may occur – ‘the possibility of a termination by resolution must be recognized.’46 However, management protocols for appendicitis today have their historical roots in a clear diagnosis and a policy of early operative intervention.
Conclusion The appendix no doubt caused death and disease in children from prehistoric times, but not until the 19th century did its pathological importance in become widely accepted. Recovery remained more a matter of luck than good management until Fitz’s seminal contribution, delivered at a time of rapid surgery advancement, ushered in an era of early surgery. Advances in anaesthesia, antisepsis, antibiotics, haemostasis and fluid therapy have made recovery almost universal, even for the very young or critically ill. As we debate ways to enhance recovery after appendicectomy or the need for appendicectomy at all, we should not forget appendicitis can be a deadly disease.
Acknowledgements Thank you to Kjetil Ertresväg for translating German texts (French texts translated by JKH). Thank you to the librarians of the University of Auckland Philson Library for assistance in retrieving articles.
References 1. Vergil. The Georics, 29BC. 2. Addiss DG, Shaffer N, Fowler BS, Tauxe RV. The epidemiology of appendicitis and appendectomy in the United States. Am. J. Epidemiol. 1990; 132: 910–25.
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3. Masoomi H, Mills S, Dolich MO et al. Comparison of outcomes of laparoscopic versus open appendectomy in children: data from the Nationwide Inpatient Sample (NIS), 2006–2008. World J. Surg. 2012; 36: 573–8. 4. Dahl R. Boy. Tales of childhood. London: Puffin Books, 1984. 5. Simillis C, Symeonides P, Shorthouse AJ, Tekkis PP. A meta-analysis comparing conservative treatment versus acute appendectomy for complicated appendicitis (abscess or phlegmon). Surgery 2010; 147: 818–29. 6. Svensson JF, Hall NJ, Eaton S, Pierro A, Wester T. A review of conservative treatment of acute appendicitis. Eur. J. Pediatr. Surg. 2012; 22: 185–94. 7. Hall NJ, Jones CE, Eaton S, Stanton MP, Burge DM. Is interval appendicectomy justified after successful nonoperative treatment of an appendix mass in children? A systematic review. J. Pediatr. Surg. 2011; 46: 767–71. 8. International Clinical Trials Registry. The CHildren’s INterval Appendicectomy (CHINA) Study CHINA, 2013. Available from URL: http:// apps.who.int/trialsearch/trial.aspx?TrialID=ISRCTN93815412. 9. Akkoyun I. Outpatient laparoscopic appendectomy in children: a single center experience with 92 cases. Surg. Laparosc. Endosc. Percutan. Tech. 2013; 23: 49–50. 10. Cash CL, Frazee RC, Abernathy SW et al. A prospective treatment protocol for outpatient laparoscopic appendectomy for acute appendicitis. J. Am. Coll. Surg. 2012; 215: 101–5, discussion 5–6. 11. Collins DC. Historic phases of appendicitis. Ann. Surg. 1931; 94: 179–96. 12. Smith GE. Anatomical report. The archæological survey of Nubia. Cairo: National Printing Department, 1908. 13. Hippocrates. The genuine works of Hippocrates; translated from the Greek with a preliminary discourse and annotations, by Francis Adams, LL. D., surgeon. London: Sydenham Society, 1849. 14. Celsus. De Medicina. Cambridge, MA: Harvard University Press, 1971. republication of the 1935 edition. 15. Cope Z. A history of the acute abdomen. London: Oxford University Press, 1965. 16. Reynolds TF. Chapter IX. On empyema. Aretæus on the causes and signs of acute and chronic disease. Philadelphia: Haswell, Barrington, and Haswell, 1841. pp. 48–49. 17. Lowenstine LJ. A primer of primate pathology: lesions and nonlesions. Toxicol. Pathol. 2003; 31 (Suppl.): 92–102. 18. Zöllner F. Leonardo da Vinci. The complete paintings and drawings. Köln: Taschen, 2007. 19. Previdi T. Jacopo Berengario da Carpi. Carpi: Nuovagrafica, 2005. 20. Berengario DC. Commentaria cum amplissimis additionibus super anatomica Mundini una cum textu ejusdem in pristinum et verum nitorem redacto [Commentary with very many additions on the anatomy of Mondino published with his original elegant text]. Bologna: Gerolamo Benedetti, 1521. 21. Deaver JB. Appendicitis. Its history, anatomy, clinical ætiology, pathology, symptomatology, diagnosis, prognosis, treatment, technique of operation, complications and sequels, 3rd edn. Philadelphia: P. Blakiston’s Son & Co, 1905. 22. Vesalius A. On the fabric of the human body. Book V, The organs of nutrition and generation: a translation of De Humani Corporis Fabrica Libri Septem/Andreas Vesalius; [translated] by William Frank Richardson in collaboration with John Burd Carman. Novaoa, CA: Norman Publishing, 2007. 23. Damper WC. A history of science, and its relations with philosophy and religion. London: Cambridge University Press, 1971. 24. Sherrington C. The endeavour of Jean Fernel. Folkstone & London: Dawsons of Pall Mall, 1974.
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25. Morer G. Histoire de l’appendicite. Première période, première partie. Des origines à Dupuytren (résumé). Hist. Sci. Med. 1978; 12: 23–32. 26. Heister L. Bon einem Geschwür in dem wurmförmigen auswaschs im blinden Darm (in processu vermiformi intestini coeci). Med. Chir. Anat. Wahrnehm. 1753; 3: 193–4. 27. Amyand C. Of an inguinal rupture, with a pin in the appendix cœci incrusted with stone; and some observations on wounds in the guts. Philosoph. Trans. R. Soc. London 1736; 39: 329–42. 28. Bingener J, Sloan JA, Ghosh K, McConico A, Mariani A. Qualitative and quantitative analysis of women’s perceptions of transvaginal surgery. Surg. Endosc. 2012; 26: 998–1004. 29. Lacher M, Muensterer OJ, Yannam GR et al. Feasibility of singleincision pediatric endosurgery for treatment of appendicitis in 415 children. J. Laparoendosc. Adv. Surg. Tech. A 2012; 22: 604–8. 30. Mestivier M. Observation sur une tumeur situee proche la region ombilicale, du côté droit, occasionnee par une grosse epingle trouvee dans l’appendice vermiculaire du caecum. Jour de med, de chir, et de pharm 1759; 10: 441–2. 31. Parkinson JWK. Case of diseased appendix vermiforms. Med. Chir. Trans. 1812; 3: 57–8. 32. Louyer-Villermay. Observations pour servir a l’histoire des inflammations de l’appendice du caecum. Arch Gen. Med. 1824; 5: 246–50. 33. Mêlier F. Mémoire et observations sur quelques maladies de l’appendice caecale. Jour gen de med, de chir et de pharm 1827; 100: 317–45. 34. Vayre P, Hillemand B. François Mélier (1798–1866). Un Limousin pionnier de santé publique et d’épidémiologie au XIXème siècle à Paris. Hist. Sci. Med. 2007; 41: 385–90. 35. Grisolle A. Des phlegmons et des abcès des fosses iliaques. Traité élémentaire et pratique de pathologie interne. Paris: Victor Masson, 1848; 529–33. 36. Dupuytren G. Des abcés de la fosse iliaque droite. Leçons orales de clinique chirurgicale 1839; 3: 516–35. 37. Goldwyn RM. Guillaume Dupuytren: his character and contributions. Bull. N. Y. Acad. Med. 1969; 45: 750–60. 38. Husson M, Dance M. Quelques engorgemens inflammatoires qui se développent dans la iliaque droite. Repert. Gen. Anat. Physiol. Pathol. 1827; 4: 74–101. 39. Menière P. Mémoire sur des tumeurs phlegmoneuses occupant la fosse iliaque droite. Arch. Gen. Med. 1828; 17: 188–218. 40. Richerand A. Classe septième. Maladies du système cellulaire. A. Abcès. Nosogr. Chir. Volume 4. Paris, 1808. 2nd edn. pp. 191–215. 41. Copland J. A dictionary of practical medicine. London: Longman, Brown, Green, Longmans, & Roberts, 1858. 42. Hodgkin T. Lectures on the morbid anatomy of the serous and mucous membranes. London: Sherwood, Gilbert and Piper, 1836. 43. Bright R, Addison T. Inflammation of the cæcum and appendix vermiformis. Elements of the practice of medicine. London: Longmans, Orme, Brown, Green, and Longmans, 1839; 498–504. 44. Leudet E. Researches anatomical, pathological and clinical on ulceration and perforation of the vermiform appendix. Arch. Gen. Med. 1859; 14: 128, 315. 45. Williams GR. Presidential address: a history of appendicitis. Ann. Surg. 1983; 197: 495–506. 46. Fitz R. Perforating inflammation of the vermiform appendix, with special reference to its early diagnosis and treatment. Am. J. Med. Sci. 1886; 92: 321–46. 47. Abel WG, Allen PD. Acute appendicitis in children. Ann. Surg. 1950; 132: 1093.
© 2013 Royal Australasian College of Surgeons
Historical aspects of appendicitis in children James K. Hamill,*† Andrew Liley‡ and Andrew G. Hill† *Paediatric Surgery Services, Starship Children’s Hospital, Auckland, New Zealand †Department of Surgery, University of Auckland, Auckland, New Zealand and ‡Department of Paediatric Anaesthesia, Starship Children’s Hospital, Auckland, New Zealand
Key words appendicectomy, appendicitis, appendix, history, post-operative pain. Corrrespondence Dr James K. Hamill, Paediatric Surgery Services, Starship Children’s Hospital, Private Bag 92024, Auckland 1142, New Zealand. Email: [email protected]
Abstract Evidence of appendicitis exists from ancient Egyptian mummies but the appendix was not discovered as an anatomical entity until the renaissance in Western European literature. Much confusion reigned over the cause of right iliac fossa inflammatory disease until the late 19th century, when the appendix was recognized as the cause of the great majority of cases. Coining the term ‘appendicitis’ and making the case for early surgery, Fitz in 1886 set the scene for recovery from appendicitis through operative intervention.
Accepted for publication 10 September 2013. doi: 10.1111/ans.12425
Felix qui potuit rerum cognoscere causas He who has been able to learn the causes of things is happy Virgil. Georgics, 29 BC.1
Introduction The lifetime risk of appendicitis is around 7–9%2 and appendicectomy is one of the most common emergency operations in children. Mortality from appendicitis in children has been recently estimated at 0.01% (non-perforated disease) to 0.06% (perforated appendicitis).3 Surviving appendicitis with complete recovery is now expected but was not always so. Author Roald Dahl was 3 years old when his 7-year-old sister, Astri, died from the disease; it was 1920. Five years later, his half-sister, Ellen, contracted appendicitis but recovered after having her appendix removed, ‘on our own nursery table at home by the local doctor and his anaesthetist.’4 Early surgery revolutionized recovery from appendicitis. Since Fitz’s seminal paper in 1886, surgeons have followed the policy of urgent appendicectomy; however, some investigators now challenge this approach. Conservative treatment of complicated appendicitis is an accepted option5,6 and the place of interval appendicectomy after conservative treatment is under investigation.7,8 On the other hand, enhanced recovery from operative treatment may soon allow routine outpatient surgery for acute appendicitis.9,10 In the light of contemporary debates, a review of the history of appendicitis is timely. In this paper, we recount the discovery of the appendix and appendicitis, from ancient Egypt, through Europe, ending in America in the late 19th century. © 2013 Royal Australasian College of Surgeons
Early history Ancient Egyptians placed the bandaged viscera of the deceased in canopic jars prior to mummification. Collins in his article, Historic Phases of Appendicitis described the inscriptions found on certain jars referring to the ‘worm’ of the bowel.11 G. Elliot Smith discovered the mummified body of a young Egyptian woman ‘in which a thick band of old “adhesion” springs from the appendix near its tip and passes over to be attached to the other side of the pelvis. It seems to be clear evidence of old appendicitis.’12 Hippocrates said, ‘From the rupture of an internal abscess, prostration of strength, vomiting, and deliquium animi result’, and ‘Suppuration upon a protracted pain of the parts about the bowels is bad.’13 Some of Hippocrates’ patients would have had appendix abscesses. Celsus (probably around the time of Christ) wrote, ‘The disease which is in the larger intestine is situated chiefly in that part which I have described as a blind alley. There is extreme flatulence, violent pains especially on the right side . . .’14 Zachary Cope in his A History of the Acute Abdomen suggests the ‘blind alley’ refers almost certainly to the caecum and appendix and the disease described could do very well for appendicitis.15 Aretæus of Cappadocia (30 AD) wrote, ‘I have myself made an incision into an abscess of the colon on the right side, near the liver, when a large quantity of pus escaped, which flowed also several days through the kidneys and bladder, and the patient recovered.’16 Collins suggests that Aretæsus had drained an appendix abscess.11 No mention of the appendix is found in the works of Aristotle (4th century BC) nor Galen (2nd century AD).11 Both based their ANZ J Surg 84 (2014) 307–310
308
anatomical discoveries on vivisection: Galen dissected pigs and the Barbary macaque; neither have an appendix.17 From this time postmortem examinations were frowned upon or forbidden15 so the works of Aristotle and Galen formed the foundation of anatomical knowledge until the renaissance.
The appendix discovered The first definite documentation of the appendix in Western European literature appeared in the renaissance. Leonardo da Vinci sketched an appendix in 1492.18 Berengario da Carpi formulated the first written description of the appendix in 1521,19,20 describing an ‘additamentum . . . empty within, and in breadth less than the smallest finger of the hand, and of a length of three inches or thereabouts.’21 Andreas Vesalius, professor of anatomy at Padua, illustrated and described the appendix in 1543, calling it ‘cæcum’ meaning blind pouch.11,22
Appendicitis discovered Jean Fernel, the French physician, mathematician and philosopher,23,24 may have made the first description of appendicitis. Morer in his History of Appendicitis translates Fernel’s 1544 account: ‘At the opening of the cadaver, we find the caecum squeezed and contracted . . . resulting in acrid and corroding material being prevented from moving on, stagnating for an unusually long time, it opening a way into the abdominal cavity, the intestine being red and perforated a short distance from the obstruction . . .’25 What of the ‘squeezed caecum’ – was Fernel using Versalius’ terminology for the appendix, and could this have been ileus in perforated appendicitis? November 1711, in the amphitheatre of the town Altdorf bei Nürnberg in Germany, Lorenz Heister, anatomist, surgeon and botanist, performed a public dissection of the body of a malefactor. Forty-two years later (1753) Heister wrote, ‘Wanting to demonstrate to the spectators the true position of the large intestine, I found the vermiform appendix of the caecum a black colour, contrary to what is natural, and more adherent than normal to the membrane of the ventral abdominal wall (called peritoneum). Wanting to isolate it by gentle traction, the tissues of the vermiform appendix tore apart, despite the cadaver being very fresh, and two or three spoonful of pus came out. This can serve as proof that in the caecum and the vermiform appendix there can exist inflammation and abscess.’26
First appendicectomy Ever since infancy, 11-year-old HanvilAnderson had a scrotal hernia. For the last month ‘a great quantity of an unkindly sort of matter’ had been discharging from a fistula at the base of the scrotum.27 In December 1735, Claudius Amyand operated on the young lad. Finding a contracted, inflamed appendix perforated by ‘a pin incrusted with stone towards the head’ he applied a ligature and performed history’s first appendicectomy.27 Amyand wrote, ‘Tis easy to conceive that this operation was as painful to the patient as laborious to me.’27 Young Hanvil recovered after a hospital stay of about a month.27 The appendicectomy by Amyand is remarkable for several reasons. It is the first recorded appendicectomy. The patient was a child. The incision via a hernia is germane in the light of modern innovative approaches, natural orifice surgery28 and single incision
Hamill et al.
laparoscopic surgery.29 Finally, it is a story of recovery following surgery, albeit slow and painful.
A fatal illness Over the subsequent century a series of post-mortems were described. Mestivier of Saint André hospital, Bordeaux performed the autopsy of a 45-year-old man after the chief surgeon had drained about a pint of pus from an abscess to the right of the umbilicus (1757). Mesivier found a pin had perforated the appendix, causing gangrenous appendicitis.30 Zachary Cope reported that John Hunter described a gangrenous appendix at the autopsy of Colonel Campbell Dalrymple.15 John Parkinson, the London surgeon who described the eponymous ‘shaking palsy’, reported a gangrenous appendix with a fecolith at the autopsy of a 5-year-old boy.31 Jean-Baptiste Louyer-Villermay described two men ‘in the strength of youth, endowed with good constitution, struck without warning, at a time of perfect health, by a most acute inflammation . . . But how can an inflammation of an organ of such small volume, and especially of such limited importance, cause such a rapid death . . .?’32 François Mêlier reported eight autopsies with appendiceal obstructions, included a 13-year-old boy with an appendix full of roundworms, and an 18-year-old adolescent with a gangrenous appendix containing several fecoliths (‘calculs’).33 Mêlier wrote, ‘If it was in fact possible to establish, in a manner certain, positive, the diagnosis of these afflictions, and that they were always well defined, one could conceive the possibility of relieving the disease, by means of an operation: we will arrive perhaps one day at this result.’33 Mêlier’s prediction would await the advent of anaesthesia and antisepsis before fulfilment. Vayre and Hillemand, in their 2007 article on Mélier,34 noted that despite such ‘reasonable analysis’Mélier’s ‘innovative idea’ was opposed by Grisolles, professor of medicine (in his 1848 Traité élémentaire et pratique de pathologie interne35) and Mélier’s own professor of surgery, Guillaume Dupuytren.36
Confusing the caecum The eccentric Dupuytren, Chief Surgeon at Paris’ Hôtel Dieu 1815– 1835, once said, ‘I have been mistaken, but I have been mistaken less than other surgeons.’37 In describing a fatal case of appendicitis in a young man be wrote, ‘These inflammations, maladies of the appendix, of which I have seen quite a large number of examples, have barely reached the attention of authors, and we owe to one of my students, M. le docteur Melier, an excellent work on the lessons of this organ.’36 In his Lectures on Clinical Surgery (published posthumously in 1939), Dupuytren described seven cases of iliac fossa abscess, six on the right, but assigned the propensity for sepsis on this side to the anatomical arrangement of the caecum, not the presence of the appendix in the right iliac fossa.36 The caecum’s retroperitoneal nature, junction with the small bowel and narrow ileocaecal valve, he believed, predisposed foreign bodies to lodge, leading to abscess formation.36 One wonders whether Dupuytren was influenced by Fernel’s case of caecal stricture and bowel obstruction described 300 years earlier. On the other hand, Dupuytren did advise his students, ‘read little, see much, do much’ (‘peu lire, beaucoup voir, beaucoup faire’).37 © 2013 Royal Australasian College of Surgeons
Historical aspects of appendicitis
Husson and Dance, Dupuytren’s colleagues at the Hôtel Dieu, described 15 cases of right iliac fossa abscess without once mentioning the appendix.38 Menière, also of the Hôtel Dieu, described two boys aged 16 and 18 years with right iliac fossa inflammatory ‘tumours’. Both recovered completely after hospital stays of 12 days and one month, respectively. Menière noted ‘the prognosis is not in general very bad, since in 16 cases observed . . . one sole individual succumbed.’ He described three clinical courses: (i) rapid improvement in symptoms with resolution of the inflammatory mass; (ii) fluctuant abscess with evacuation of pus per anus and recovery; (iii) general peritonitis with a guarded prognosis.39 Clearly, recovery without surgery was possible even before the days of antibiotics, and can be seen as an historical basis contemporary management practices such as the non-operative management of an appendix mass. Gottfried Goldbeck, a student at the University of Giessen, read Husson and Dance’s paper, and on the advice of his teacher, Professor Puchelt, Goldbeck wrote his M.D. thesis on Inflammation in the Right Iliac Fossa. In it he relates a story (as recounted by Zachary Cope): ‘A boy aged ten had eaten a lot of cherries together with their stones; soon after eating them he fell from a wagon and after about eight days presented the following symptoms of disease. He was in a feverish condition, complained of constipation and a definite pain in the right iliac region which felt distended, rigid, and tender with painful spasms on urination. These symptoms were accompanied by an attack of ileus . . . All treatment was of no avail and the patient died. The post-mortem showed the following: The caecum was quite filled with faeces and cherry stones and was in a gangrenous condition. The neighbouring part of the peritoneum and the bladder were inflamed. In the blind end of the vermiform process there was a cherry stone impacted in the neighbourhood of which the wall of the process was distended, gangrenous and perforated and surrounded by a collection of pus.’15 Despite so clearly describing perforated appendicitis, Goldbeck concludes his thesis, ‘I therefore venture to propose the designation “Perityphlitis” for this disease . . .’15 emphasizing the caecum (Gk, τυφλος, typhlos, blind). Why were these authors preoccupied with the caecum but ‘blind’ to the appendix? Morer in his History of Appendicitis25 suggests the answer may lie in Richerand’s 1805 textbook of surgical pathology: ‘We give the name abscess to all collections of pus formed in soft tissue . . . we do not use the name abscess for collections of purulent fluid in serous cavities of the meninges, pleura, peritoneum or synovia.’40 The retroperitoneal caecum, understood to be in contact with the soft tissues of the iliac fossa, thus could form pus, but the appendix, surrounded by peritoneum, apparently could not.
Solving the riddle Around the first half of the 19th century, several authors recognized appendiceal inflammation. James Copland, in his Dictionary of Practical Medicine wrote of inflammation of the caecum, ‘There are few diseases more defined in their character . . . It may attack the vermiform appendix only, or the cellular tissue connecting the cæcum to the internal iliac muscle.’41 Thomas Hodgkin (discoverer of Hodgkin disease) stated in his Lectures, ‘inflammation of the peritoneum, in the Iliac fossa, is sometimes set up by disease in the Appendix cæci.’42 Hodgkin describes three degrees of inflammation: (i) ‘very limited’; © 2013 Royal Australasian College of Surgeons
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(ii) perforated but limited to the right iliac fossa; (iii) diffuse, which ‘quickly proves fatal’.42 Richard Bright and Thomas Addison of Guy’s Hospital in their 1839 publication, Inflammation of the Cæcum and Appendix Vermiformis stated, ‘from numerous dissections it is proved that the fæcal abscess thus formed in the right iliac region arises, in a large majority of cases, from disease set up in the appendix cæci.43 It is found that this organ is very subject to inflammation, to ulceration, and even to gangrene.’43 Émile Leudet in Researches Anatomical, Pathological and Clinical on Ulceration and Perforation of the Vermiform Appendix stated, ‘the appendix ileo-cæcal is in effect a quite frequent cause of localised inflammation . . . perforation of the appendix ileo-cæcal is, of all the parts of the intestine, the one observed perhaps the most frequently.’44 Leudet reviewed 30 of his own observations including three boys (aged 8, 16 and 17 years) who succumbed to appendicitis.44 Leudet was ahead of his time, since it would be another 27 years before appendiceal inflammation was widely accepted by the surgical community. In June 1886, Harvard professor Reginald Fitz read a paper titled, Perforating Inflammation of the Vermiform Appendix, before the first meeting of the Association of American Physicians.45 Fitz analysed 257 cases and reviewed the literature. He stated, ‘it seems preferable to use the term appendicitis to express the primary condition.’46 Despite the word mixing a Latin word (appendere, to hang upon) with a Greek suffix (-itis, pertaining to) ‘appendicitis’ entered the parlance of surgeons and achieved universal recognition. Osler referred to the meeting as ‘the coming of age party of clinical medicine in America.’45 Abel credits Fitz with ‘solving of the riddle of appendicitis.’47 Fitz acknowledged spontaneous recovery may occur – ‘the possibility of a termination by resolution must be recognized.’46 However, management protocols for appendicitis today have their historical roots in a clear diagnosis and a policy of early operative intervention.
Conclusion The appendix no doubt caused death and disease in children from prehistoric times, but not until the 19th century did its pathological importance in become widely accepted. Recovery remained more a matter of luck than good management until Fitz’s seminal contribution, delivered at a time of rapid surgery advancement, ushered in an era of early surgery. Advances in anaesthesia, antisepsis, antibiotics, haemostasis and fluid therapy have made recovery almost universal, even for the very young or critically ill. As we debate ways to enhance recovery after appendicectomy or the need for appendicectomy at all, we should not forget appendicitis can be a deadly disease.
Acknowledgements Thank you to Kjetil Ertresväg for translating German texts (French texts translated by JKH). Thank you to the librarians of the University of Auckland Philson Library for assistance in retrieving articles.
References 1. Vergil. The Georics, 29BC. 2. Addiss DG, Shaffer N, Fowler BS, Tauxe RV. The epidemiology of appendicitis and appendectomy in the United States. Am. J. Epidemiol. 1990; 132: 910–25.
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3. Masoomi H, Mills S, Dolich MO et al. Comparison of outcomes of laparoscopic versus open appendectomy in children: data from the Nationwide Inpatient Sample (NIS), 2006–2008. World J. Surg. 2012; 36: 573–8. 4. Dahl R. Boy. Tales of childhood. London: Puffin Books, 1984. 5. Simillis C, Symeonides P, Shorthouse AJ, Tekkis PP. A meta-analysis comparing conservative treatment versus acute appendectomy for complicated appendicitis (abscess or phlegmon). Surgery 2010; 147: 818–29. 6. Svensson JF, Hall NJ, Eaton S, Pierro A, Wester T. A review of conservative treatment of acute appendicitis. Eur. J. Pediatr. Surg. 2012; 22: 185–94. 7. Hall NJ, Jones CE, Eaton S, Stanton MP, Burge DM. Is interval appendicectomy justified after successful nonoperative treatment of an appendix mass in children? A systematic review. J. Pediatr. Surg. 2011; 46: 767–71. 8. International Clinical Trials Registry. The CHildren’s INterval Appendicectomy (CHINA) Study CHINA, 2013. Available from URL: http:// apps.who.int/trialsearch/trial.aspx?TrialID=ISRCTN93815412. 9. Akkoyun I. Outpatient laparoscopic appendectomy in children: a single center experience with 92 cases. Surg. Laparosc. Endosc. Percutan. Tech. 2013; 23: 49–50. 10. Cash CL, Frazee RC, Abernathy SW et al. A prospective treatment protocol for outpatient laparoscopic appendectomy for acute appendicitis. J. Am. Coll. Surg. 2012; 215: 101–5, discussion 5–6. 11. Collins DC. Historic phases of appendicitis. Ann. Surg. 1931; 94: 179–96. 12. Smith GE. Anatomical report. The archæological survey of Nubia. Cairo: National Printing Department, 1908. 13. Hippocrates. The genuine works of Hippocrates; translated from the Greek with a preliminary discourse and annotations, by Francis Adams, LL. D., surgeon. London: Sydenham Society, 1849. 14. Celsus. De Medicina. Cambridge, MA: Harvard University Press, 1971. republication of the 1935 edition. 15. Cope Z. A history of the acute abdomen. London: Oxford University Press, 1965. 16. Reynolds TF. Chapter IX. On empyema. Aretæus on the causes and signs of acute and chronic disease. Philadelphia: Haswell, Barrington, and Haswell, 1841. pp. 48–49. 17. Lowenstine LJ. A primer of primate pathology: lesions and nonlesions. Toxicol. Pathol. 2003; 31 (Suppl.): 92–102. 18. Zöllner F. Leonardo da Vinci. The complete paintings and drawings. Köln: Taschen, 2007. 19. Previdi T. Jacopo Berengario da Carpi. Carpi: Nuovagrafica, 2005. 20. Berengario DC. Commentaria cum amplissimis additionibus super anatomica Mundini una cum textu ejusdem in pristinum et verum nitorem redacto [Commentary with very many additions on the anatomy of Mondino published with his original elegant text]. Bologna: Gerolamo Benedetti, 1521. 21. Deaver JB. Appendicitis. Its history, anatomy, clinical ætiology, pathology, symptomatology, diagnosis, prognosis, treatment, technique of operation, complications and sequels, 3rd edn. Philadelphia: P. Blakiston’s Son & Co, 1905. 22. Vesalius A. On the fabric of the human body. Book V, The organs of nutrition and generation: a translation of De Humani Corporis Fabrica Libri Septem/Andreas Vesalius; [translated] by William Frank Richardson in collaboration with John Burd Carman. Novaoa, CA: Norman Publishing, 2007. 23. Damper WC. A history of science, and its relations with philosophy and religion. London: Cambridge University Press, 1971. 24. Sherrington C. The endeavour of Jean Fernel. Folkstone & London: Dawsons of Pall Mall, 1974.
Hamill et al.
25. Morer G. Histoire de l’appendicite. Première période, première partie. Des origines à Dupuytren (résumé). Hist. Sci. Med. 1978; 12: 23–32. 26. Heister L. Bon einem Geschwür in dem wurmförmigen auswaschs im blinden Darm (in processu vermiformi intestini coeci). Med. Chir. Anat. Wahrnehm. 1753; 3: 193–4. 27. Amyand C. Of an inguinal rupture, with a pin in the appendix cœci incrusted with stone; and some observations on wounds in the guts. Philosoph. Trans. R. Soc. London 1736; 39: 329–42. 28. Bingener J, Sloan JA, Ghosh K, McConico A, Mariani A. Qualitative and quantitative analysis of women’s perceptions of transvaginal surgery. Surg. Endosc. 2012; 26: 998–1004. 29. Lacher M, Muensterer OJ, Yannam GR et al. Feasibility of singleincision pediatric endosurgery for treatment of appendicitis in 415 children. J. Laparoendosc. Adv. Surg. Tech. A 2012; 22: 604–8. 30. Mestivier M. Observation sur une tumeur situee proche la region ombilicale, du côté droit, occasionnee par une grosse epingle trouvee dans l’appendice vermiculaire du caecum. Jour de med, de chir, et de pharm 1759; 10: 441–2. 31. Parkinson JWK. Case of diseased appendix vermiforms. Med. Chir. Trans. 1812; 3: 57–8. 32. Louyer-Villermay. Observations pour servir a l’histoire des inflammations de l’appendice du caecum. Arch Gen. Med. 1824; 5: 246–50. 33. Mêlier F. Mémoire et observations sur quelques maladies de l’appendice caecale. Jour gen de med, de chir et de pharm 1827; 100: 317–45. 34. Vayre P, Hillemand B. François Mélier (1798–1866). Un Limousin pionnier de santé publique et d’épidémiologie au XIXème siècle à Paris. Hist. Sci. Med. 2007; 41: 385–90. 35. Grisolle A. Des phlegmons et des abcès des fosses iliaques. Traité élémentaire et pratique de pathologie interne. Paris: Victor Masson, 1848; 529–33. 36. Dupuytren G. Des abcés de la fosse iliaque droite. Leçons orales de clinique chirurgicale 1839; 3: 516–35. 37. Goldwyn RM. Guillaume Dupuytren: his character and contributions. Bull. N. Y. Acad. Med. 1969; 45: 750–60. 38. Husson M, Dance M. Quelques engorgemens inflammatoires qui se développent dans la iliaque droite. Repert. Gen. Anat. Physiol. Pathol. 1827; 4: 74–101. 39. Menière P. Mémoire sur des tumeurs phlegmoneuses occupant la fosse iliaque droite. Arch. Gen. Med. 1828; 17: 188–218. 40. Richerand A. Classe septième. Maladies du système cellulaire. A. Abcès. Nosogr. Chir. Volume 4. Paris, 1808. 2nd edn. pp. 191–215. 41. Copland J. A dictionary of practical medicine. London: Longman, Brown, Green, Longmans, & Roberts, 1858. 42. Hodgkin T. Lectures on the morbid anatomy of the serous and mucous membranes. London: Sherwood, Gilbert and Piper, 1836. 43. Bright R, Addison T. Inflammation of the cæcum and appendix vermiformis. Elements of the practice of medicine. London: Longmans, Orme, Brown, Green, and Longmans, 1839; 498–504. 44. Leudet E. Researches anatomical, pathological and clinical on ulceration and perforation of the vermiform appendix. Arch. Gen. Med. 1859; 14: 128, 315. 45. Williams GR. Presidential address: a history of appendicitis. Ann. Surg. 1983; 197: 495–506. 46. Fitz R. Perforating inflammation of the vermiform appendix, with special reference to its early diagnosis and treatment. Am. J. Med. Sci. 1886; 92: 321–46. 47. Abel WG, Allen PD. Acute appendicitis in children. Ann. Surg. 1950; 132: 1093.
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