Appendicitis At 100

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On Sunday, January 17,1886, a twenty-four-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, three hundred thousand potentially lifesaving 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, Rudolf Kr’f6nlein of Zurich “cut off in toto” the appendix of a stricken seventeen-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 forty-yearold 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.”