University of Illinois Hospital & Health Sciences System, Chicago, Illinois, United States (Summer 2013)
What we define appendicitis today is a relatively recent clinical picture that was well-described only in the 19th century. This is in part due to the difficult anatomic identification of the appendix. Although scholars believed to find possible descriptions of appendix in the work of Hippocrates, strong arguments against the existence of appendix were based on the fact that the knowledge of anatomy relied for twelve centuries mostly on the writings of Galen (c. 130–201), whose anatomic studies were mainly done on monkeys, which do not have the appendix. Nevertheless, in Galen or later in authors from the School of Salerno (c. 800–1100), accurate descriptions of small bowel pain may indeed have been related also to appendicitis.
Of interest are the medieval writings of John of Arderne (1307–1390?). He was the earliest of English surgeons and left many writings in which he refers to himself as “Magister Johannes de Arderne,” to indicate that he was an educated master surgeon not to be confused with barber surgeons very active in practice at his time.1 John left many writings that were widely read for over 200 years. Particularly he wrote a treatise on the passio iliaca which may represent one of the first documents on appendicitis, although the description of this condition applied also to intestinal obstruction.
The first description of the appendix was reported by the Italian anatomist Berengario da Carpi (1460–1530), professor at the University of Bologna, in his Commentaria (1521) where he described an empty small cavity (addentramentum) at the end of the cecum. In 1543 De Humani Corporis Fabrica, Andreas Vesalius (1514–1564) then insisted on the appendix (Figure 1) as one of the three openings of the cecum together with the ileum and the colon. Gabriel Falloppius (1523–1562) seemed to be the first to compare the appendix to a worm (vermiformis) in 1561.
Appendicitis and appendectomy in the 18th and 19th centuries
A post-mortem section of appendicitis was initially described by the leading German surgeon of the 18th century, Lorenz Heister (1638–1758), in 1711. Nevertheless, Garrison comments that “while the pathologic appearances, clearly described in the autopsy, had already been noted by Heister (1711), yet these landmarks left no impression upon practice whatever.”2
What we can consider the first report on an operated case of appendicitis is described by Claudius Aymand (1681–1740) who operated on an 11-year-old boy with a right scrotal hernia and a fistula. He identified the appendix, perforated by a pin within the scrotum, ligated the appendix and then removed it.3
The first operation for acute appendicitis was instead performed by J. Mestivier in 1759.4 Mestivier described the case of a 45-year-old patient admitted to St. Andrew Hospital in Bordeaux for a mass localized on the right side of the umbilical area. The mass was fluctuant and was opened. A pint of pus came out. The patient died shortly after and during the autopsy it was found that the abscess had started from a small pin covered with salts perforating the appendix.5 The description of symptoms, possibly attributed to the pain of appendicitis, is found in the work of the German physician J.P. Frank, who writes of this picture as peritonitis muscularis in 1792.
The first case in which perforation of appendix was recognized as the cause of death was reported in 18126 by John Parkinson (1755–1824), son of the more famous James renowned for describing Parkinson’s disease. The case presented by John Parkinson was also the first case of appendicitis published in English. In 1813, Wegeler described7 in detail the case of an 18-year-old patient admitted for mild abdominal spasms for 3 days, followed by an acute and localized pain in the right lower quadrant, increasing at minimal palpation. The abdomen was tender, patient had constipation that was preceded by mild diarrhea, nausea and vomiting. The next day the extremities became cold and the patient died. On autopsy, there was a generalized peritonitis and the cecum was gangrenous. Wegeler commented that “this alteration seemed to start from the appendix that was red, enlarged and filled with stones.” In 1824 two more cases of appendix perforation with fatal peritonitis were reported8 in a classic paper by the French physician Louyer-Villemay. Only a few years later, in 1827, the French Francois Melier (1798–1866) was the first to describe what today is a chronic appendicitis and suggested a surgical approach.9
The first successful operation addressing an intestinal perforation due to an abscess of the appendix, was reported by the English surgeon Henry Hancock (1809–1880) at the Charing Cross Hospital in London.10 This case was then followed in 1867 by the first in the US11 authored by Willard Parker (1800–1884) from Francistown, NY. Parker advocated the opening of appendicular abscesses at an early stage. Other cases of successful operation of appendectomy with survival of the patients are from Richard John Hall in 188612 and Frank Woodbury in 1887.13 The latter wrote of a successful case operated by the surgeon Thomas George Morton (1835–1903):
The vermiform appendix was greatly swollen and exhibited a perforating ulcer extending three-fourths around its circumference and very near to the point of origin. A silk ligature was applied close to the caecum and at the terminal part of the appendix, and the intervening portion, comprising almost the whole organ was removed together with a large part of the omentum, which projected into the abscess cavity. The walls were then scraped with a curette and douched with simple warm water.
Interestingly, the term “appendicitis” was introduced only in 1886 by Reginald Heber Fitz (1843–1913) in Boston and replaced the more generic “typhlitis” and “perityphilitis.” He gave conclusive demonstrations of the pathology of perforating inflammation of the vermiform appendix in a series of 25 cases.14 The most common sign of acute appendicitis, the “McBurney’s point,” was named after and described by the New York surgeon Charles McBurney (1845–1913) in 1889.15 The description of the site of pain in his famous article is the following:
The seat of greatest pain, determined by the pressure of one finger, has been very exactly between an inch and a half and two inches from the anterior spinous process of the ileum on a straight line drawn from the process to the umbilicus.
After 1890, the modern history of appendectomy was started with many surgeons who refined the operation proposing different approaches. The beginning of the 20th century corresponds also to the dawn of modern pathology, including accurate histological diagnosis of appendicitis, such as illustrated in 190816 by the renowned German pathologist Ludwig Aschoff.
- Mathews F.S. John of Arderne. Bull N Y Acad Med. 1930; 6: 461–471.
- Garrison F.H.. An Introduction to the History of Medicine, Philadelphia: W.B. Saunders Company, 1929, 4th ed., p. 344.
- Aymand C. Philosophical Transactions of the Royal Society of London, 1736, 39: 329–336
- Mestivier J. Journ. gen. de med. et de chir., 1759, X, 441.
- Talamon C. Appendicite e peritiflite, Torino, Unione Tipografico-Editirice, 1894, p.16.
- Parkinson J. Med. Chir. Trans. London, 1812, iii, 57.
- Wegeler, Journ. de med. et de chir., 1813.
- Louyer-Villermay. Arch. gen. de med. Paris, 1824, v, 246-250.
- Melier F. Memoire et observations sur quelques maladies de l’appendice cecale. J. gen. med. 1827.
- Hancock H. Disease of the appendix caeci cured by operation. Lond. Med. Gaz. 1848, 7, 547-550.
- Parker W. An operation for abscess of the appendix vermiformis caeci. Med Rec. (NY), 1867, 2, 25-27.
- Hall RJ. Suppurative peritonitis due to ulceration and suppuration of the vermiform appendix; laparotomy; resection of the vermiform appendix; toilette of the peritoneum; drainage; recovery. NY Med J, 1886, 43,662-662.
- Woodbury F. Trans. Coll. Phys. Philad. 1887, 9, 183.
- Fitz RH. Perforating inflammation of the vermiform appendix…Trans. Ass. Amer. Phys. 1886, 1,107-44.
- McBurney C. Experience with early operative interference in cases of disease of the vermiform appendix. NY Med.J. 1889, 50, 676-684.
- Aschoff L. Die Wurmfortsatzentzundung. Jena, Fisher, 1908.
DAMIANO RONDELLI, MD, is the Michael Reese Professor of Hematology, Chief of the Division of Hematology/Oncology and Director of the Blood and Marrow Transplant at the University of Illinois Hospital & Health Sciences System, Chicago, IL. He initially completed his medical school and fellowship in hematology, and then started his academic career at the University of Bologna, Italy. He joined the University of Illinois at Chicago in 2002. His research interests are both in preclinical models and clinical trials in stem cell transplantation. He is the author of over 100 scientific peer-reviewed articles, multiple book chapters, and is the editor of the book, Storia delle Discipline Mediche [History of Medical Disciplines], Edizioni Hippocrates, Milano 1999 and 2003. He is the Chair of the Chicago chapter of ISSNAF (Italian Scholars and Scientists of North America Foundation) and a fellow of the Institute of Medicine of Chicago (IOMC).
Highlighted in Frontispiece Summer 2013 – Volume 5, Issue 3