Appendicitis, Appendectomy, and the Surgeon

Surgery, in the twentieth century, provides an important part of the health-care armamentarium, but one that is sometimes difficult to evaluate. Much depends on the individual surgeon’s technique and judgment. For some particularly innovative and difficult procedures technique is crucial, as it is in certain fragile and complex cases; but more commonly, the important issues in surgical therapy are those surrounding surgical judgment—operating (or not) with the proper techniques, on the proper patient, at the proper time. For the few nontraumatic surgical conditions that existed in 1870, relatively little surgical judgment was required—pain of sufficient intensity called for lithotomy, blindness from cataracts called for their removal, and so forth. The excitement of “safe” surgery in the 1880s led to scores of new procedures or operations, most of which are no longer practiced. One, because of its phenomenal success, became paradigmatic: the management of appendicitis by early appendectomy. Appendicitis and its operative treatment serve as a window on the emergence of surgical therapy as the twentieth century began. In 1890 only a few practitioners saw appendicitis as an exclusively surgical disease to be managed by an experienced surgeon, with an appropriate operation as the most likely therapy. In 1920 their position was dominant, both within the American medical profession and among the general public, and the experience with appendicitis would be used in other debates to both explain and campaign for the validity of surgical judgment and the wider understanding of surgical disease.

William Osler, in the 1892 (first) edition of his now-classic medical textbook, wrote: “Appendicitis . . . is one of the most important of intestinal affections. Unfortunately, much confusion still exists about the forms of inflammation in the caecal region.” ¹ Reginald Heber Fitz had described appendicitis in 1886, and Osler was one of the physician-pathologists who accepted the need to operate on patients with perforation of the appendix but felt there were many cases that resolved under medical management. Led by William Pepper of Philadelphia, and including Fitz, the prominent medical authorities of the day all described the problem as a diagnostic and prognostic one. Disease of the appendix was indicated by “sudden pain in the right iliac fossa with fever, localized tenderness with or without tumor [tumor meant any palpable mass].” ² Many patients presenting with these symptoms recovered without surgery. The confusion of Osler and others concerned when to ask for a surgical consultation and when to recommend an operation.

A small, radical group of surgical authorities in the last decade of the nineteenth century saw the issues in very different terms. They advocated the idea that today we call “surgical judgment”; as W. W. Keen phrased it in 1891, “The very first indication . . . is to call in the surgeon.” ³ Improved patient care in appendicitis, they argued, required both redefining the disease and redefining realms of professional authority. In the last third of the nineteenth century surgical innovators worldwide began to argue for the safety of operations generally, and for earlier surgical interventions, while patients were better able to withstand the “shock” of surgical assault. ⁴

A subset of this general effort was seen in the American campaign for the operative management of perityphlitis in the 1870s and 1880s. In the period 1886–89 this campaign was transformed by Fitz’s definition of appendicitis. In 1889 three papers appeared based upon the operative experiences of their authors, Charles McBurney, Nicholas Senn, and John Murphy, arguing that the appendix gave all the symptoms of perforation before perforation actually occurred and that it should be removed uninjured without spilling septic products into the abdomen. Based upon their experience that at least some medically managed pa-tients had repeated attacks of appendicitis, and on the repetitive operative experience of finding an inflamed but unperforated appendix following diagnosis of perforation, these surgeons redefined appendicitis as an invariably dangerous, surgical disease. ⁵ McBurney introduced a new diagnostic sign—the point of maximal tenderness—to make early diagnosis easier. Early diagnosis would allow for much lower postoperative morbidity and mortality. Based on his experience, with both varying symptoms and varying degrees of...