Abstract
Background
Save for the contribution of Charles McBurney, who described his eponymous point and the appendicectomy incision, the history of appendicectomy is largely unknown among the medical profession. This review traces the history from the first anatomical depiction of the appendix to the development of open appendicectomy and the recent minimally invasive and non-operative methods.
Methods
Historical articles, monographs and books containing anatomical descriptions of the vermiform appendix and reports of appendicitis and its surgical treatment were retrieved after searching the PubMed, Google Scholar and Embase databases from their inception to 31 March 2022.
Results
The first inadvertent appendicectomy was performed during an operation for a groin hernia by Cookesley in 1731, and Mestivier was the first to drain a right iliac fossa abscess, due to appendicitis, in 1757. Krönlein performed the first appendicectomy for acute appendicitis in 1884 but his patient died. The first successful appendicectomy for acute appendicitis leading to patient survival was by Morton in 1887. In 1976, Wirschafter and Kaufman performed an inadvertent colonoscopic appendicectomy and, in 1980, Semm carried out the first laparoscopic appendicectomy. The first appendicectomy via a natural orifice (transgastric) appendicectomy was by Rao and Reddy in 2004.
Conclusion
This historical review charts the development of surgical knowledge concerning the management of appendicitis, from the first anatomical drawings of the appendix and descriptions of appendicitis to the development of surgical and conservative treatments up to the present day. It also corrects some inaccuracies of attribution in previous historical reviews.
Similar content being viewed by others
Introduction
The origins and evolution of appendicectomy appear to be shrouded in a degree of mystery, with varying accounts and different surgeons being cited and given credit by various authors [1,2,3,4,5]. The most widely known name is that of Charles Herber McBurney, owing to his description of the point of tenderness on the abdominal wall and the incision for appendicectomy which carry his name [6]. However, appendicectomy predates his work by more than a century.
The aim of this review was to trace the origins of appendicectomy, by reference to the original literature, and to outline an accurate history of this widely practiced operation as well as other aspects of management.
Methods
The methods employed for this review are described in Table 1.
Anatomical descriptions
The first recorded anatomical drawing of the appendix was that of Leonardo Da Vinci, circa 1508 [7] (Fig. 1) and the first written narrative of the appendix was by Berengarius of Carpi in 1522 [8], who described it as “its shape appeareth strictly compacted, but within it is empty, and is less in breadth than the least finger of the hand, and it is of the length of three inches or thereabouts”.
It was subsequently depicted by the anatomist Andreas Vesalius in De Humani Corporis Fabrica Libri Septem in 1543 [9]. Giovanni Battista Morgagni also produced drawings of the appendix in his 1719 book [10], showing that the appendix had a lumen which was in continuity with the caecum.
Diagnosis
The history of the diagnosis of acute appendicitis is confusing, with a variety of descriptions such as “typhilits”, “perityphilitis” and “iliac passion”, until the pathologist Reginald Herber Fitz (Fig. 2), in a review of 257 cases in 1886, popularised the idea that the vermiform appendix was the cause of acute right iliac fossa inflammation and ensuing abscesses [11].
Prior to this, the earliest description of a supposed case of appendicitis was credited to Desiderius Erasmus by Seal [3] quoting Cope [12]. In a letter, written in 1530, Erasmus describes a 3-month illness with abdominal pain, with subsequent development of a hard swelling and an abscess, which was finally incised. However, on closer scrutiny of more recent translations of Erasmus’ correspondence, his symptoms were on the left side of his abdomen [13], making appendicitis unlikely.
Another possible description of acute appendicitis was made in 1554 by Joannis Fernel [14] (Fig. 2), when he described the autopsy finding of a perforation in the caecum of a 7-year-old girl who died following a short history of abdominal pain. However, whether this represented a case of appendicitis is disputed, as the appendix itself was not described [2].
The first definitive account of appendicitis was published by Lorenz Heister (Fig. 2) in 1753, in which he described pathological findings of a perforated appendix with a surrounding abscess at an autopsy performed in 1711 [15].
Drainage of right iliac fossa abscesses, without appendicectomy
The first published account of an operation to drain an abscess in the right iliac fossa, resulting from disease of the appendix, was performed by Mestivier in 1757 [16]. Unfortunately, the patient died soon after the procedure, and autopsy revealed a perforation of the appendix by a large pin to be the source of the abscess.
The first publication of a successful operation, with survival of the patient, to drain an appendix abscess in the right iliac fossa, was by Henry Hancock (Fig. 3) in 1848 in a young woman who had gone into premature labour, four days after developing right sided abdominal pain [17]. Fourteen days after the onset of pain, and after she had deteriorated significantly, Hancock made a four-inch incision in her right iliac fossa under chloroform anaesthesia, which caused discharge of “a quantity of excessively offensive turbid serum”. Two weeks later a “small round ball of faecal matter, surrounded by calcareous deposit” was discharged from the wound that had been left open. Hancock concluded that this may have been impacted in the appendix and escaped when it ulcerated.
However, there may have been an operation which predates that of Hancock. A letter by Willard Parker (Fig. 3), published in 1867 [18], describes an operation performed on a local physician in 1843 for an abscess in the right iliac fossa which had developed after several weeks of abdominal pain and fever. Parker describes cutting down and evacuating pus together with a “little concretion, the size of a raisin seed”. The patient recovered and was “in good health” at the time of publication [18].
Robert Lawson Tait (Fig. 3) also described a series of cases of drainage of abscesses associated with typhlitis, the earliest of which was in 1867 [19].
Incidental appendicectomies during operations for groin herniae
The best-known early report of an operation to remove an appendix is by Claudius Amyand in 1735 (Fig. 3) [20]. He described an 11-year-old boy undergoing an operation for a right groin hernia which had developed an enterocutaneous fistula. Amyand opened the hernial sac and encountered the “appendix cœci” (sic), which had been perforated by a pin. He proceeded to amputate the appendix and ligate its base and left the wound to heal by secondary intention.
A report by a “surgeon apothecary” (forerunner of general practitioners) called William Cookesley, not published until 1742 [21], describes an operation performed on Abraham Pike, a chimney sweep, in 1731 for a strangulated inguinal hernia. Cookesley excised necrotic small bowel and the patient recovered. When the patient died 31 years later, an autopsy in 1763 by John Symons, a surgeon from Exeter and pupil of William Hunter, revealed an intact small bowel, but a missing caecal pole and appendix [22]. Symons sent Hunter the excised bowel who prepared and preserved the specimen which is now in the Hunterian Museum in Glasgow. Thus, it may be that Cookesley carried out the first appendicectomy (albeit inadvertently) during his treatment of a hernia.
Appendicectomy through abdominal incisions
The first documented appendicectomy through an abdominal incision was performed by Tait (Fig. 3) in 1880 and published in 1890 [19]. He describes operating on a 17-year-old woman, with a three-month history of abdominal pain, who developed a right lilac fossa swelling and whom he believed to have generalised peritonitis. He made a midline incision without finding any pus, but when he made an incision “over the caecum” (which we may assume to be a separate skin incision) he found a large abscess containing a gangrenous appendix which he removed, burying the stump. The patient survived and left hospital a month later.
The first recorded appendicectomy through an abdominal incision for acute appendicitis was by Rudolf Ulrich Krönlein (Fig. 3) in 1884 on a 17-year-old blacksmith who had 3 days of abdominal pain and published in 1886 [23]. Using the antiseptic techniques of Lister, Krönlein performed a lower midline laparotomy and evacuated a large amount of pus from the right iliac fossa. He found a circular pea-sized hole in the middle of the appendix and went on to doubly ligate the base of the appendix followed by resection. Unfortunately, the patient died two days later.
The second record of this operation for acute appendicitis, which this time the patient, a 26-year-old man who had suffered from 3 years of episodic abdominal pain, survived, was by Thomas George Morton (Fig. 3) in 1887 and published in 1888 [24]. The episode leading to surgery had started 3 days previously and was now associated with fever. Morton considered him to be “in the dying stages of general purulent peritonitis”. After an abdominal incision, an abscess cavity was encountered, within which he found the caecum and a diseased appendix. He describes a “phosphatic concretion resembling a cherry stone” lying alongside the appendix having been extruded from a perforating ulcer near its base. The appendix was ligated at its base and excised. The patient made an uneventful recovery and was alive a year later at the time of publication.
Morton also described a second patient who had been suffering from intermittent abdominal pain and vomiting for 4 years in whom in 1886 he drained a large amount of foetid pus from a right iliac fossa abscess [24]. However, neither the appendix nor caecum were identified, and the patient was left with an open wound for 5 months. During a recurrent episode in 1888 her appendix was identified in the abscess cavity, with a perforation at its base, and was ligated and excised. Again, the patient survived.
Incisions
Prior to the use of midline incisions [23], the classical incision for draining abscesses in the right iliac fossa was that described by Hancock, starting at the anterior superior iliac spine and extending medially, parallel to Poupart’s ligament [17]. McBurney’s (Fig. 3) gridiron incision, first described in 1894 [25], is still widely used for open appendicectomy. Over the subsequent 10 years, further incisions were described, varying between vertical and transverse (Table 2) [17, 23, 25,26,27,28,29,30,31].
Non-operative management
After a rapid increase in the number of operations for appendicitis in the late nineteenth century, suggestions concerning more conservative delayed management were first voiced by Albert John Ochsner in 1902 [32]. In his Handbook of Appendicitis, he advocated delayed management if a trained surgeon with appropriate assistants or an appropriate environment was not immediately available, or if the patient was too unwell to “bear the shock of an operation”. In this pre-antibiotic era Ochsner advocated the provision of morphine and gut rest as management in some cases.
Delayed treatment was refined by James Sherren, with the resultant protocol being named the Ochsner-Sherren treatment [33]. This protocol called for delayed appendicectomy in patients, without generalised peritonitis, presenting with greater than 48 h duration of symptoms. Patients were admitted for bedrest and gut rest, but in this modification no morphine was provided. Prior to this, in 1889, D’arcy Power recognised that “simple appendicitis” may resolve spontaneously when he wrote, “It may be accepted as an axiom that a case of appendicitis which has been properly diagnosed and well treated should recover, for medical treatment will be adopted in the simple cases, and the surgeon will be summoned as soon as the inflammation ceases to run a straight forward course” [34].
Auto-appendicectomy
The most widely known case of a surgeon removing his own appendix was that of Leonid Ivanovich Rogozov, a Russian surgeon who was the only medical professional on an Antarctic expedition in 1961 [35]. After two days of no improvement with antibiotics, he performed his own appendicectomy under local anaesthesia with the aid of a mirror and three non-medically trained assistants.
It seems, however, that this landmark procedure had been attempted at least 50 years previously (reported in 1912) by an American surgeon Bertram F. Alden, who started his own appendicectomy while under spinal anaesthesia [36]. However, when one of his assistants threatened to leave the theatre unless he stopped, he allowed that assistant to complete the operation [36]. A complete auto-appendicectomy was performed in 1921 by another American surgeon Evan O’Neill Kane [37]. With the aid of three surgically trained assistants, Kane operated, in his own case of uncomplicated acute appendicitis, using only morphine preoperatively and local anaesthesia to the abdominal wall. He made a 3.5-inch-long oblique incision at one inch below the McBurney’s point, which is believed to be longer than the incision he would have normally made because of the uncertainty of operating on himself. Kane also used silk ligature to bury the stump of the appendix, which he claimed to be a method of his own. The pain remained bearable throughout the operation and he made a smooth recovery. He, therefore, advocated the use of local over general anaesthesia in appropriate cases. Kane believed the success of his auto-appendicectomy could be generalised to a wider context—“I wish to emphasize my statement that any surgeons, if not obese, can, with perfect ease and even comfort, self-operate in cases such as mine.” [36].
Laparoscopic appendicectomy
Stimulated by developments in gynaecological diagnostic laparoscopy, the first laparoscopic appendicectomy was performed by Kurt Semm, a gynaecologist, on 13th September 1980 [38]. His original description involved a 4-port technique, where the appendix was displayed by tying a Roeder knot about its tip, and then the mesoappendix ligated by an extracorporeally thrown knot. Following this, the mesoappendix was cut from the appendix and two Roeder loops applied to the base. The base was then divided and the stump invaginated using both a laparoscopically applied purse-string suture and a subsequent Z-stitch.
Natural orifice endoscopic surgery
Wirtschafter and Kaufman from California reported the inadvertent endoscopic removal of an inverted appendix in 1976 [39]. The patient underwent a colonoscopy having had a filling defect in her caecum identified on a barium enema. During the colonoscopy, what was thought to be a caecal polyp was removed with a hot snare. The histology report showed the tissue to be “consistent with appendix, showing marked autolysis”. The patient developed right iliac fossa pain three days after the procedure, but was treated with antibiotics and made a full recovery.
The wide adoption of laparoscopic appendicectomy led to interest in peroral transgastric appendicectomy, the first report of which was made at the Annual Congress of the Society of Gastrointestinal Endoscopy of India by Reddy and Rao in 2004 and presented again in 2016 [40]. The first trans-vaginal appendicectomy was reported by Chinnusamy Palanivelu and colleagues in 2008 [41]. There has also been a report of an intentional colonoscopic appendicectomy by Tao Chen and colleagues [42], for a sessile serrated caecal polyp involving appendicular orifice rather than appendicitis, the defect being closed with endoscopic clips.
Antibiotic therapy
Although appendicectomy had been the mainstay of treatment for appendicitis since the late nineteenth century, it was not until the introduction of antibiotics that some surgeons began to consider non-operative management not only for the treatment of appendicular abscesses, but also for acute appendicitis. In 1956, Eric Coldrey promoted the practice of conservative management for patients with greater than 24 h of symptoms [43]. His regimen consisted of free intake of water by mouth, and six-hourly injections of 250,000 units of penicillin and 0.5 g streptomycin. He recommended chloramphenicol, chlortetracycline, tetracycline, or sulphadimidine for “severe” cases. This strategy remained controversial, with the first randomised clinical trial of antibiotic therapy versus appendicectomy not being published until 1995 [44]. The most recent systematic review of 8 randomised clinical trials comparing antibiotic treatment with antibiotics for uncomplicated appendicitis demonstrated the former to be safe [45]. However, 38% of patients randomised to antibiotic treatment required an appendicectomy and had a sixfold greater readmission rate by 1 year [45]. In addition, a randomised clinical trial has shown that a placebo is as effective as antibiotics for the treatment of uncomplicated acute appendicitis [46].
Conclusion
This review has charted the descriptions and treatments of appendicitis from the first anatomical drawings of the appendix to the recognition of appendicitis and development of appendicectomy, as well as novel forms of management. It has also attempted to correct some of the inaccuracies of attribution in previous reviews and the timeline is summarised in Table 3.
References
Edebohls GM (1899) A review of the history and literature of appendicitis. Reprint from the Medical Record, November 25, 1899. The Publishers’ Printing Company, New York
Kiser JC (1964) Iliac passion: a history of appendicitis. Wis Med J 63:371–376
Seal A (1981) Appendicitis: a historical review. Can J Surg 24:427–433
Smith DC (1996) Appendicitis, appendectomy, and the surgeon. Bull Hist Med 70:414–441
Williams GR (1983) Presidential address: a history of appendicitis. With anecdotes illustrating its importance. Ann Surg 197:495–506
McBurney C (1889) Experiences with early operative interference in cases of disease of the vermiform appendix. N Y Med J 50:1676–1684
Clayton M, Philo R (2012) Leonardo da Vinci Anatomist. Royal Collection Publications, London
Jackson H, Larkey SV, tum Suden L (1934) Jackson’s English translation of Berengarius of Carpi’s “Isagogae Breves”, 1660 and 1664. Isis 21:57–70
Vesalius A (1555) Andreae Vesalii Bruxellensis, Invictissimi Caroli V. Imperatoris medici, de Humani corporis fabrica Libri septem. Per Ioannem Oporinum, Basileæ
Morgagni JB (1719) Animadversio XIV Adversaria Anatomica Tertia (Quorum tria posteriora nunc primùm prodeunt) Novis pluribus aereis tabulis, & universali accuratissimo indice ornata. Opus nunc vere absolutum, inventis, & innumeris observationibus, ac monitis refertum, quibus universa humani corporis anatome, & res medica, & chirurgica admodum illustrantur). Excudebat Josephus Cominus, Vulpiorum aere, Patavii
Fitz RH (1886) Perforating inflammation of the vermiform appendix; with special reference to its early diagnosis and treatment. Am J Med Sci 92:321–345
Cope Z (1965) A history of the acute abdomen. Oxford University Press, Oxford
Dalzell A, Estes JM (2015) Erasmus’ illness in 1530. In: The Correspondence of Erasmus: Letters 2204-2356 (August 1529–July 1530). University of Toronto Press, Toronto, p 409–412
Fernel J, Plancy G (1610) Intestinorum morbi causæ & signa. In: Joannis Fernelii Ambiani Universa Medicina: Ab ipso Quidem Authore ante obitum diligenter recognita, & iustis accessionibus locupletata. Marnii, Hanover, p 302–308
Heister L, Wirgman G (1755) Medical, chirurgical, and anatomical cases and observations ... With [VIII] copper-plates ... Translated from the German original by George Wirgman. J Reeves for C Hitch and J Baldwin, London
Mestivier M (1759) Observation sur une tumeur, située proche la région ombilicale, du côté droit, occasionnée par une grosse épingle trouvée dans l’appendice vermiculaire du cæcum. J de Med Chir Phar 10:441–442
Hancock H (1848) Disease of the appendix caeci cured by operation. Lond Med Gazette 7:547–550
Parker W (1867) An operation for abscess of the appendix vermiformis cæci. Med Rec (NY) 2:25–27
Tait L (1890) Surgical treatment of typhlitis. Birmingham Med Rev 27(26–34):76–89
Amyand C (1735) VIII. Of an inguinal rupture, with a pin in the appendix cæci, incrusted with stone; and some observations on wounds in the guts. Philos Trans R Soc 39:329–342
Cookesley W (1742) A considerable share of the intestines cut off after a mortification in a hernia and cured by Mr William Cookesley surgeon in Crediton. In: Medical essays and observations revised and published by a society in Edinburgh. A Society in Edinburgh, Edinburgh, p 427–431
Selley P (2016) William Cookesley, William Hunter and the first patient to survive removal of the appendix in 1731: a case history with 31 years’ follow up. J Med Biogr 24:180–183
Krönlein RU (1886) Ueber die operative Behandlung der acuten diffusen jauchig-eiterigen Peritonitis. Arch für Klin Chir 33:507–524
Morton TG (1888) The diagnosis of pericæcal abscess, and its radical treatment by removal of the appendix vermiformis. JAMA 10:733–739
McBurney C (1894) IV. The incision made in the abdominal wall in cases of appendicitis, with a description of a new method of operating. Ann Surg 20:38–43
Rockey AE (1905) Transverse incisions in abdominal operations. Med Rec (NY) 68:779–780
Davis GG (1906) XI. A transverse incision for the removal of the appendix. Ann Surg 43:106–110
Lanz O (1908) Der McBurney’sche Punkt. Zentralbl Chir 7:185–190
Battle WH (1895) Modified incision for removal of the vermiform appendix. BMJ 2:1360
Rutherford Morrison J (1896) Cases of appendicitis, with remarks. In: Surgical contributions from 1881–1916 Volume II Abdominal surgery. John Wright and Sons Ltd., Bristol, p 190–233
Delany HM, Carnevale NJ (1976) A “Bikini” incision for appendectomy. Am J Surg 132:126–127
Ochsner AJ (1902) A handbook of appendicitis. Engelhard, Chicago
Bailey H (1930) The Ochsner-Sherren (delayed) treatment of acute appendicitis: indications and technique. BMJ 1:140–143
Power D (1899) The prognosis and modern treatment of appendicitis. Br Med J 2:1467–1470
Rogozov LI (1964) Self operation. Soviet Antarctic Expedition Inf Bull 4:223–224
(1912) Doctor operates on himself: astonishing experiment. Evening Post 83:7 https://paperspast.natlib.govt.nz/newspapers/EP19120401.2.69. Accessed 20 Oct 2022
Kane EO (1921) Autoappendectomy: a case history. Int J Surg 34:100–102
Semm K (1983) Endoscopic appendectomy. Endoscopy 15:59–64
Wirtschafter SK, Kaufman H (1976) Endoscopic appendectomy. Gastrointest Endosc 22:173–174
Rao GV. World's First Transgastric Appendectomy from AIG Recap, Replay & Resurge @ DDW 2016 San Diego, 2016. https://twitter.com/gvraoaig/status/735082068267270145. Accessed 20 Oct 2022
Palanivelu C, Rajan PS, Rangarajan M et al (2008) Transvaginal endoscopic appendectomy in humans: a unique approach to NOTES–world’s first report. Surg Endosc 22:1343–1347
Chen T, Xu A, Lian J et al (2021) Transcolonic endoscopic appendectomy: a novel natural orifice transluminal endoscopic surgery (NOTES) technique for the sessile serrated lesions involving the appendiceal orifice. Gut 70:1812–1814
Coldrey E (1956) Treatment of acute appendicitis. Br Med J 2:1458–1461
Eriksson S, Granstrom L (1995) Randomized controlled trial of appendicectomy versus antibiotic therapy for acute appendicitis. Br J Surg 82:166–169
Herrod PJJ, Kwok AT, Lobo DN (2022) Randomized clinical trials comparing antibiotic therapy with appendicectomy for uncomplicated acute appendicitis: meta-analysis. BJS Open 6:zrac100
Park HC, Kim MJ, Lee BH (2017) Randomized clinical trial of antibiotic therapy for uncomplicated appendicitis. Br J Surg 104:1785–1790
Acknowledgements
The authors thank Emily Colley, Library Assistant at Nottingham University Hospitals Library Services for her help in obtaining some of the full text articles.
Funding
This study was supported the Medical Research Council [Grant Number MR/K00414X/1]; and Arthritis Research UK [Grant Number 19891]. The funders had no role in the design or conduct of the study nor in the decision to publish the findings. This article does not represent the views of the funders.
Author information
Authors and Affiliations
Contributions
PJJH, ATK and DNL conceptualised the study and performed the literature search; PJJH, ATK and DNL participated in writing and reviewing of the manuscript and have read and approved the final manuscript; DNL provided overall supervision. All authors had access to the data.
Corresponding author
Ethics declarations
Conflict of interest
None of the authors has a conflict of interest to declare.
Copyright statement
All images that accompany the article are more than 75 years old, and hence outwith copyright rules. All sources have been attributed.
Data sharing
There are no original data to share. Full texts of works cited in this review will be available for sharing upon reasonable request (Dileep.Lobo@nottingham.ac.uk).
Ethics statement
As this was a narrative review, ethics approval was not necessary.
Provenance and peer review
Not commissioned, externally peer-reviewed.
Protocol registration
As this was a narrative review, protocol registration was not necessary.
Additional information
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.
About this article
Cite this article
Herrod, P.J.J., Kwok, A.T. & Lobo, D.N. Three Centuries of Appendicectomy. World J Surg 47, 928–936 (2023). https://doi.org/10.1007/s00268-022-06874-6
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00268-022-06874-6