History of Medicine

THE LITTLE APPENDAGE

     Wait a minute – don’t take out that appendix!

     This sounds like heresy, but a recent article in JAMA (June 16, 2015) showing the near equivalency of antibiotics and surgery as treatment for appendicitis suggests a non-surgical approach as an alternative. Controversy over the appendix and appendicitis is hardly new, but how far back does it go?

    Berengario daCarpi, the famous anatomist and the first to describe anatomical structures based on his own human dissections, is credited with the first description of the appendix (1521). 
     Leonardo da Vinci included it in earlier anatomic drawings, but they were not published until the 18^th century. His translated comment on the structure is: "The auricle (appendix) n, of the colon, n m, is a part of the monoculus (caecum) and is capable of contracting and dilating so that excessive wind does not rupture the monoculus." (See right lower part of drawing.)

By Leonardo da Vinci, probably 1504-6. From Leonardo da Vinci on the Human Body by C.D. O'Malley and  J.B.de C.M. Saunders, 1952. Courtesy Hathi Trust.

From Vesalius' De Fabrica, Book 5. (Courtesy Biu Sante,Paris)

Vesalius showed the appendix clearly. He felt it should be called the caecum but the name appendix prevailed. 


     After experiments in removing the appendix (in animals) and noting its absence in certain animals it was later deemed to have no important function. Rare cases of perforated or gangrenous appendix were described at autopsy in the 18^th century, including one by John Hunter. More cases followed, and in 1827 Francois Mêlier described four fatal cases plus two from another surgeon, all showing at autopsy abdominal pus and a diseased appendix adjacent to an apparently healthy caecum. Mêlier was the first to suggest the possibility of surgery for the condition. 

Guillaume Dupuytren.  (From Wikipedia and Wellcome  Images)

     His opinion, however, was contradicted by Guillaume Dupuytren, the most prominent surgeon of the time, who felt that a diseased caecum was the culprit. Dupuytren’s exalted status and his abrupt personality apparently finished the argument, though it was largely academic since surgeons rarely ventured into the abdomen. Richard Bright and Thomas Addison, however, in their 1839 text (Elements of the Practice of Medicine) specifically mention “ulceration….of the vermiform process of the caecum” as a cause of acute peritonitis, as did occasional other writers. Names like “typhlitis” (cecal inflam-mation) and “paratyphlitis” (peri-cecal inflammation/pus) were given to the clinico-pathologic picture.        

Reginald Fitz. (From Nat. Library of Medicine)

     The issue was laid to rest by Reginald Fitz, professor of pathological anatomy at Harvard and a practicing surgeon. He had studied with Virchow (and others) in Europe and introduced the microscope into the Harvard medical school curriculum at the time of Charles Eliot’s presidency. His 1886 article in the American Journal of the Medical Sciences laid out the clinical and pathologic features of the disorder, using the word “appendicitis” for the first time, after which the vagaries of “typhlitis” and “paratyphlitis” died out. Most important, he recommended removal of the appendix as treatment. Other surgeons concurred, and contributed to raising appendectomy from a rare to a relatively common operation over the next decade. This was the age of anesthesia and “Listerism”, and a reduced fear of abdominal surgery.

     But the first surgeries had mixed results and controversies arose about when to operate, how to make the incision, how to predict perforation, and so on. William Osler pondered this problem. His extensive autopsy experience had taught him that appendicitis could heal by itself, or could resolve and recur. In the first edition of his text, 1892, he advised that "severe" cases have surgery. In mild cases it depended in part on the availability and skill of the surgeon, though he recognized that predicting perforation was chancy. On the other hand, he said, medical treatment could “be expressed in three words – rest, opium, and enemata”. Four years later, in the second edition, Osler was admitting cases directly to the surgical ward, warning that delays in surgery could be fatal, even though results from surgery were only fair at the time. Harvey Cushing's case (see below) illustrates the dilemma.  
     In Osler’s time the press had extensively publicized appendicitis, extolling the marvelous wonders of surgery, something Osler commented on in the 1896 edition: “There is a well-marked appendicular hypochondriasis (italics mine). Through the pernicious influence of the daily press, appendicitis has become a sort of fad, and the physician has often to deal with patients who have a sort of fixed idea that they have the disease. The worst cases of this class which I have seen have been in members of our profession…”
     Results improved over time and surgical treatment has prevailed until the present - now perhaps to be replaced by antibiotic therapy in early cases.

     

     A couple of interesting “appendicitis anecdotes”:

    1)  Harvey Cushing, as a resident at Hopkins, developed appendicitis and was operated on by William Halstead and two other surgeons (Finney and Bloodgood), with a slow recovery.

Harvey Cushing by Edmund Tarbell, from Wikipedia

Cushing wrote out his own history and examination (see insert). Fulton, his biographer, says, “The new operation had been performed several times at the Hopkins prior to his (Cushing’s) advent in Baltimore, but the results had not been particularly encouraging and Halstead was still reluctant to recommend it.” Halstead had little experience with it, in fact. Cushing knew this but pushed to operate, and left instructions with a friend on how to distribute his things in case of death.

     

{From Fulton's life of Cushing (Google Books)}

  2)  The coronation of King Edward VII, following the death of Queen Victoria, was scheduled for June 26, 1902. Fourteen days before, Edward developed abdominal pain and fever. He was seen by several physicians and improved with general measures. After a large pre-coronation banquet on the 25th Edward’s symptoms relapsed severely, and he was told by Sir Frederick Treves (and four other physicians in attendance) that he needed immediate surgery. When he protested that he had to attend his coronation, Treves told him, “Then, Sir, you will go as a corpse.” At surgery an abscess was opened and drained, and the appendix left in. He recovered. Treves was made a Baronet and accumulated a huge private practice, though his daughter, ironically, died of appendicitis.

Works consulted:

Smith, Dale: “Apendicitis, Appendectomy, and the Surgeon”. Bull Hist Med, 1996. v 70:414-441.

Melier, F: “Memoire et Observations sur Quelques Malades de l’Appendice coecale”. J Generale de Medecine, de Chirurgie, et de Pharmacie 1827, p 317.

Fitz, R. “Perforating Inflammation of the Vermiform Appendix”. Amer J Med Sci. 1886, 92:321-346.

Williams, G R. A History of Appendicitis. Ann of Surgery 1983. 197: 495-506.

Osler, William: Principles and Practice of Medicine, 1892 and 1896.

Fulton, J. Harvey Cushing: A Biography. 1946.

Bliss, Michael. Harvey Cushing: A Life in Surgery. 2005.

C D O'Malley, J B de C M Saunders: Leonardo da Vinci on the Human Body, 1952 (available at Hathi Trust web site)