Appendicitis At 100

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Though Prescott was clearly in the dangerous dark ages relative to the management of the captain’s disease, he knew no less than the physicians who treated the woman in Boston seventy-one years later. There were intervening sparks of enlightenment, but they all failed to throw permanent light on the problem until Reginald Fitz came along.

Reginald Heber Fitz was born on May 5, 1843, in Chelsea, Massachusetts. After receiving his M.D. from Harvard in 1868, he studied for two years, first in Vienna and then in Germany under Rudolf Virchow, generally regarded as the father of pathology. Returning to Boston in 1870, Fitz received appointments as a microscopist at the Massachusetts General Hospital and as an instructor in pathological anatomy at Harvard Medical School. He rose quickly at Harvard, becoming assistant professor in 1873 and Shattuck Professor of Pathological Anatomy in 1879.

The secret to preventing infection: Get in quick and get out quicker.
 

A student recollected, “His lectures were terse, vigorous, lucid and models of flawless didactic exposition, and in clinical exercises his cross-examination method and keen forensic style were as illuminating as they were stimulating. …” According to a colleague, Fitz was “not an investigator in the sense that he carried out or led original, experimental research,” yet his “penetrating clearness of vision … enabled him to extract, as could no one else, from a mass of apparently unrelated observations, the concise, clear clinical picture.”

Fitz’s pathbreaking paper, entitled “Perforating Inflammation of the Vermiform Appendix; With Special Reference to Its Early Diagnosis and Treatment,” was read before the Association of American Physicians, June 18,1886, and was published in the American Journal of the Medical Sciences the following October. It contained a meticulous point-by-point analysis of 466 cases of abdominal disorders that had previously been variously diagnosed and showed that they all involved a diseased appendix. Moreover, Fitz demonstrated that the disease always started at the appendix. He wrote that “variations in length, position and patency [of the appendix], whether congenital or acquired, are of obvious importance in explaining many of the apparent differences in the clinical histories.” Being an astute clinician, Fitz went on to set forth simple and effective methods both of diagnosis and of treatment, and he concluded his monumental study with three fundamental statements: the early recognition of appendicitis is of vital importance; its diagnosis is usually not difficult; and its treatment by appendectomy is generally indispensable.

 

Another truly important thing Fitz did in his paper was to introduce the term appendicitis . Some two dozen names had previously been used for what had been thought to be a variety of diseases. The new, single name would help eliminate this confusion. Some years later he commented, “The word was coined by me purely for practical purposes. I wished to call attention to inflammation of the vermiform appendix as … that to which treatment was directly to be applied. … The subject is now so well understood that its nomenclature seems of minor importance … [but] I much prefer appendicitis to Fitz’ disease.”

Many considered appendicitis a clumsy or “barbarous” word, and some suggested substitutes, such as apophysitis and scolecoiditis . Not a few physicians, especially in remoter areas of the country, began to believe there were now two distinct diseases that afflicted the right iliac fossa—typhlitis (a prevalent older term) and appendicitis. For a number of years to come, typhlitis, perityphlitis, and even “stoppage of the bowels” would continue to be used alongside appendicitis.

Nevertheless, 1886 remained the year of conquest—the “year of appendicitis.” As Howard Kelly, a surgeon and member of the first medical faculty at Johns Hopkins, aptly put it, “Now everything was to be changed and as a tangled skein full of knots and false clues yields at once to the hand which holds the right thread, so the perplexities, obstacles, and unfounded notions which hitherto blocked the way, disappeared as soon as Fitz’ paper supplied and enforced the acceptance of the correct fundamental fact—that the multifarious abdominal disorders hitherto variously named were all no more than forms and stages of inflammation of the appendix.”

To some extent this classic paper was a reaffirmation of the views of many earlier investigators, some of whom were as perspicacious and articulate as Fitz. However, by 1886 the time was ripe for the medical profession to focus on appendicitis and to develop the operation to combat it. And Fitz was the right man to spark the change. He was a pathologist, not a surgeon, and thus could command respect in both of these then sometimes uncooperative fields.