Appendicitis At 100


Who did the first appendectomy? As noted earlier, Rudolf Kr’f6nlein performed one in 1884, but the patient died. In 1886, Richard Hall, a New York surgeon, removed an appendix and the patient lived. But Hall had diagnosed the case as “strangulated hernia.” In 1887, Thomas Morton, a prominent Philadelphia surgeon, became the unchallenged first to deliberately and successfully operate for and remove an inflamed ruptured appendix after having made the correct diagnosis. Less than a year later, he was the first to diagnose and remove an inflamed appendix that had not yet ruptured. His interest in the operation may have been more than clinical. His brother and son both died of appendicitis.

Morton’s accomplishments initiated a period of quickened interest in Fitz’s revelations, and scores of skilled and famous surgeons now began making major contributions. In 1889 Charles McBurney, a New York surgeon, published a paper in which he pinpointed the tenderness and pain associated with appendicitis at a point one and a half to two inches from the protuberance of the right hip in the direction of the navel. John Deaver, a turn-of-the-century pioneer in abdominal surgery, considered this the greatest of all advances in the diagnosis of appendicitis, “not so much because the pain is in every case just at the spot, but because it put into the physicians’ and surgeons’ thoughts, in a practical concrete way, a ready method of excluding nearly every other disease with almost certainty.” With that aid to diagnosis, a real psycho- logical barrier had been removed and the number of surgeons willing to amputate the appendix increased by leaps and bounds. And with practice came the development of standard techniques.

The value of swift action was confirmed by the experience of a surgeon named John Murphy. By 1894 he had performed 108 operations with a loss of 10 lives, an astonishing success rate, considering that the majority of the cases had not been seen until rupture. The secret to preventing infection, as Murphy put it, was, “Get in quick and get out quicker.”

Further advances included discovery of the salutary effect of raising the head of the peritonitis patient’s bed eighteen inches or so, to facilitate the gravitational flow of fluids in the least dangerous direction; withholding all food before operating to keep the intestines inactive; and avoidance of laxatives and cathartics. For all intents and purposes, basic surgical procedures had all been established by the early years of the twentieth century. Between 1925 and 1955 the mortality rate for the operation decreased from 14 percent to one-tenth of one percent. Innovations during this period included, in approximate order of their introduction, improved anesthesia, nasogastric suction, blood transfusions, intravenous fluids, penicillin, and broad-spectrum antibiotics.

Today the treatment of simple, acute appendicitis—when the trouble has not progressed beyond the confines of the appendix—is one of the safest surgical procedures and one in which there is no disagreement among the surgeons except concerning such fine points as the type of incision to make or what to do with the “stump.” A perforated, ruptured appendix, though, remains an emergency. It still can kill.

Fitz and the appendectomy helped put the United States on the road to becoming the world leader in surgery. By the turn of the century America was well ahead of Europe and Great Britain in abdominal surgery. The uncrowned king of England and his personal physicians brought this point home in 1902, when Edward VII was felled by “perityphlitis,” as stated in the official announcement from Buckingham Palace. Edward had been sick for several weeks and was taking laxatives all the while. After his appendix ruptured, he was finally operated on, just three days before his coronation. He lived to assume the throne, and only then did the appendectomy become widely accepted in Britain.

The king was subsequently accused by some of making the appendectomy a new medical fashion. If he did so, he was just following in the footsteps of Fitz.