The Reginald Fitz Memorial Hall - The History of Appendicitis

reginald fitz

Reginald Heber Fitz (1843-1913)

No one has ever been entirely sure of the function of the appendix; it is attached to the gut, but appears to have no role in digestion. The appendix is also only variably present in animals – hominid apes have appendices, but monkeys do not. Rabbits and wombats have appendices, but dogs and cats do not.(Theobald) The lack of obvious function and the variability of presentation led the Natural Philosophers, Darwin included,(Darwin) to classify the appendix as vestigial, a harmless little evolutionary accident that could be safely ignored.

As a result, the sudden onset of pain in the right lower quadrant associated with fever, chills, and then peritonitis was thought for centuries to be due to an inflammation of the cecum, and diseases of the cecum were noted with the Greek root typhos, or blind, since the cecum represents a “blind pouch” of the colon. Pain in the right lower quadrant with evidence of inflammation was typhlitis, except when there was bloody dysentery as well, in which case the diagnosis was typhoid.

There were countervailing arguments variably made through the 18th and 19th centuries that the vermiform appendix was in fact the source of this sudden, often catastrophic illness. In 1711 Lorenz Heister described the blackened stump of an acute gangrenous appendix in his dissection of an executed criminal (who presumably went to the gallows with significant abdominal pain). Hunter, Bright, Addison, and Parkinson all described appendiceal disease in monographs published between 1767 and 1839. In 1880, the appendix was first removed in a planned operation by Dr. Lawson Tait.(Williams)

In 1886 Reginald Fitz of Boston published his monograph on diseases of the vermiform appendix, and coined the term appendicitis to separate this disease from inflammations of the cecum and small bowel. (Fitz) Frederick Treves, author of the well regarded 1883 monograph Applied Surgical Anatomy,(Frederick Treves Surgical Applied Anatomy) performed the first appendiceal surgery in England for the “new disease” appendicitis in 1887.

Initially, there was considerable controversy surrounding the proper treatment of appendicitis after Fitz’s monograph in 1886, and there were three distinct schools of thought on proper treatment of this new disease. The first group centered around McBurney and Murphy in the United States and advocated emergent removal of the appendix during the acute illness.(McBurney; Williams) A second advocated purely non-operative therapy for appendicitis, insisting on a bland diet and rest, and arguing that if the patient survived the initial inflammation and perforation, that the body would care for the abscess in its own way.(Tilden) A third group argued for emergent removal of non-ruptured appendicitis, and delayed surgery for appendicitis that was already ruptured and accompanied by an intraabdominal abscess. Frederick Treves was the leading advocate of this camp, and he presented a very well received paper on the Inflammation of the Vermiform Appendix, to the West London Medico-Chirugical Society on Friday, June 20th, 1902, two days after he first consulted with King Edward VII for his appendicitis. In his paper he describes his extensive experience with appendicitis, and argues quite cogently for moderation in the clinical approach to appendicitis.

Ironically, Frederick Treves' successful treatment of the Appendicitis of King Edward VII with operative drainage of the abdominal abscess made appendectomy fashionable: the King’s acute appendicitis also had a profound effect on public awareness of appendicitis, and of awareness of appendectomy.

…after the historic operation on the King appendicitis and the operation for its cure became increasingly fashionable on both sides of the Atlantic. The Mayo brothers, for instance, in America performed 12 operations for appendicitis in 1895, 186 in 1900 and over a thousand in 1905.(Stevenson)

Appendectomy became the treatment of choice for appendicitis. The public was rigorously educated about appendicitis and the risks of rupture, the virtues of early diagnosis. The Philadelphia project and other efforts at public education led to a century long standard of care for emergency appendectomy for all cases of appendicitis. Interestingly, in the last fifteen to twenty years, surgery has realized that drainage of ruptured appendices with a delayed, or "interval" appendectomy is a reasonable, and probably safer approach to appendiceal abscess than is emergency surgery, coming full circle to Treves' original approach.