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They had not yet discovered the appendix, but early physicians were familiar with the distinctive pain in the lower right quadrant whose name evolved over time from the ancient passio iliaca to colic passion, then to typhlitis and perityphilitis (from the Greek tuphlon enteron, “blind intestine,” i.e., the cecum), and finally, in 1886, to appendicitis, when Boston surgeon Reginald Heber Fitz published “Perforating inflammation of the vermiform appendix with special reference to its early diagnosis and treatment” in The American Journal of Medical Science.13

  As a medical malefactor, the appendix is small potatoes. True, when angered and ignored, it can turn lethal. But appendicitis is not contagious like the plague; when it kills, it does so one body at a time. The infection does not linger hidden for years like syphilis, slowly rotting your body and brain, nor does it leave its victims alive but paralyzed, as polio may. An acute infection may spread, but appendicitis is not secretive like cancer, quietly savaging its way through the body. Yet, as one researcher wrote as late as 2010, “Though appendicitis is fairly common, it still remains a frustrating medical mystery … we know surgical removal is an effective treatment, [but] we still don’t know the purpose of the appendix, nor what causes it to become obstructed.”14

  Nothing new here; their predecessors didn’t know, either. Early on, an irritated appendix was blamed on a variety of causes, most commonly something the victim had swallowed, which then became stuck in the appendix, a proposal resting on what seemed an uncommonly common Victorian appetite for pins and other unusual objects such as fruit pits. Whatever the cause, the problem was treated with useless and often gruesome remedies. As late as the 17th century, Thomas Sydenham, the English physician commonly regarded as the father of modern medicine, favored applying the sliced-open body of a freshly killed puppy to the painful abdomen. If that didn’t work, he advised horseback riding to bounce problematic matter out of the cecum. Other therapies for “deplorable iliac passions” included bloodletting, laxatives, crouching in a hot oil and herb sitzbath, and even swallowing lead pellets to stimulate intestinal movement. As one medical historian reported: “An autopsy on a man who had died of the iliac passion and who had been made to swallow three large balls [in the hope of overcoming the obstruction], showed these same balls in the appendix, which was dilated by fecal matter nearly, to the size of the rest of the gut.”15, 16

  For the ancients, the surest sign of abdominal trouble was an abscess on the skin resulting from an infection underneath. Greek, Islamic, and early Christian physicians approached these abscesses with great caution, preferring to wait until they “pointed” (came to a head), at which time they might insert a sharp instrument of one kind or another to open and drain the area. Even this surgery was customarily avoided until the last possible moment in favor of allowing the infection to burst on its own or letting the patient die without the added burden of an incision and sparing the physician the possibility that the corpse’s relatives might cry, “Murder.”

  Eventually, braver men began to claim credit for not only puncturing the abscess but also having performed the first appendectomy. The short list of those claiming to have been Number One in extracting an inflamed appendix from a living human body includes but is definitely not limited to:

  • English military surgeon Claudius Amyand (1735)

  • French surgeon Jean-Vincent-de-Paule Mestivier (1759)

  • English surgeon Henry Hancock (1848)

  • New York College of Physicians and Surgeons professor Willard Parker (1867)

  • British Surgeon Robert Lawson Tait (1880)

  • Polish-Austrian experimental biologist Johann von Mikulicz-Radecki (1884)

  • Swiss surgeon Rudolph Ulrich Krönlein (1884)

  • Philadelphia surgeon Thomas G. Morton (1887)17

  Unfortunately, their stories are rather like sightings of UFOs: plentiful and exciting but not necessarily what they seem. The procedures they described range from (1) opening and “cleaning out” the appendix to (2) removing part of the appendix and tying off the rest to (3) actually cutting out the entire organ. As a result, Frederick Treves wrote to The Philadelphia Medical News in 1892, “Who first excised the appendix some musty and forgotten tome will no doubt reveal in the course of time.”18

  Despite their admirable daring, like the doctors before them, these men lost many if not most of their patients. Harvey Cushing (1869–1939), commonly known as the “father of neurosurgery,” lost one of his, which naturally left him apprehensive when his own appendix became inflamed in 1897. Happily, Cushing’s offending organ was successfully removed by the equally eminent surgeon William Halsted (1852–1922), founder of America’s first school of surgery and the man who introduced radical mastectomy as a surgical option for breast cancer. Despite a somewhat complicated recovery, Cushing did indeed survive,19 and as time went on, other surgeons began to pile up their own successes. In 1898, Augustus Charles Bernays (1854–1907), who performed the first successful caesarian section in St. Louis in 1889, reported having performed seventy-one appendectomies without a single fatality, a record stunningly eclipsed six years later by John B. Murphy (1857–1916), one-time president of the American Medical Association, who claimed two thousand successful appendectomies.20 With this, the operation emerged as a matter of serious interest and an important marker in the transition to the modern era of medical surgery. By 1889, more than 2,500 articles about the appendix had been published in the growing number of medical journals, but even then surgeons contemplating the “the worm” faced several vexing questions.21

  “It must not be said, then, that the resection of the appendix is a simple and easy operation,” the Parisian surgeon Charles Talamon wrote in his classic work Appendicite et pérityphlite (1892). “It is sometimes extremely painful; and the surgeon, in proposing the operation, should be prepared for every difficulty and every surprise.”22 Was the appendix really to blame for a patient’s abdominal misery? In the absence of blood tests to prove an increased white cell count signifying infection or an X-ray to show masses in the appendix, how was one to make a certain diagnosis? And, even if the appendix was the problem, was the condition acute, requiring immediate surgery, or was it relapsing/recurrent/chronic (translation: repeated attacks over a short period of time), conditions Talamon described in detail?23 Even if the condition were acute, should the surgeon operate immediately or wait to see whether the condition resolved on its own, the “interval surgery” pioneered by Sir Frederick Treves in 1888.24 With these uncertainties in mind, full acceptance of appendectomy had to wait a while. As late as 1923, the fifth edition of Merck’s Manual, a series widely regarded as the bible of contemporary orthodox American medical practice, was still advising external medication including methylenis coerulei (gentian violet) and internal remedies such as the potentially poisonous bismuth subnitatis (“an intestinal antiseptic”). It was not until 1940, having dropped the possessive “s” in its name, that the Merck Manual endorsed appendectomy as the “only reasonable prospect of cure.” In 1950, when the number of journal articles on appendicitis had risen to 13,000, the Manual deemed surgery “imperative.” And with the experience of World War II battlefield medicine still fresh in everyone’s mind, the authors completed the triad of surgical “A’s”—anesthesia, antisepsis, antibiotics—by recommending penicillin before and after the operation.25

  Today, as noted, appendectomy is the most common emergency operation in the United States and the most common surgery for children. Since 1979, the total number of appendectomies in the United States has held steady at 250,000–300,000 a year, virtually all of them pretty much a no-frills, routine affair, in at morning, home by night. While the lifetime risk of developing an inflamed appendix is slightly higher for males than for females, the lifetime risk of losing the appendix to the knife is two times higher for women than for men, a result, perhaps, of the greater number of “incidental appendectomies” (prophylactic removal of the appendix during surgery for another condition) among women 35–44 yea
rs old.26, 27

  Is all that cutting justified? As surgery has become safer, the question has become more complicated.

  For nearly 300 years after Claudius Amyand claimed to have performed the first appendectomy in 1735, physicians argued for and against immediate surgery as the best way to prevent rupture of the appendix that might spread infection through the patient’s body. Recently, however, surgeons have begun to treat appendicitis not with a scalpel but with antibiotics. Several new studies show that for children with uncomplicated appendicitis, a condition marked by, among other things, a low white blood cell count, meaning that the body has not felt the need to muster its complete army of anti-infection soldiers. The pills appear to work as well as the knife. In one example with 102 children, half of whom had appendectomies, those who had surgery experienced more complications than those on antibiotics, although two of the latter patients did return to the hospital for surgery within a month. As the study’s authors at Nationwide Children’s Hospital (Columbus, Ohio) reported in the Journal of the American Medical Association, “With antibiotics, the pain’s gone almost immediately. But some don’t want to risk having the pain come back, and for them the best option is to choose surgery. Both are safe. Both are reasonable.”28

  The remaining question, of course, is exactly what kind of appendicitis the patient has, a fact that pretty much determines treatment. “Perforating appendix” is a term used to mean that the inflamed organ has actually burst, spilling infected material into the body; “nonperforating appendix” means the infection is contained. These are different situations. Does one require surgery and the other not? Is there such a thing as chronic appendicitis, a continuing low-grade infection, which can be cured with antibiotics? Should a person heading for a place where it might be hard to find a surgeon in an emergency, say Antarctica or outer space, sacrifice the appendix before going (no, astronauts are not required to have appendectomies before leaving earth)? How about a woman of childbearing age who isn’t planning to leave home but might develop appendicitis while pregnant? And, most prosaically, if the appendix really is useless, why not simply remove it soon after birth? The answers are maybe, maybe, maybe, maybe, and useless? Says who?

  And before you jump into the controversy, consider this: one may argue about the value of the appendix as an appendix, but not as surgical tissue. For nearly half a century, surgeons have salvaged and used the appendix to repair a ureter damaged by genetic inheritance, traumatic accident, or during surgery.

  WINSTON’S TRIPLE COMPLAINT

  One evening in October 1922, when 48-year-old Winston Churchill, Colonial Secretary in Lloyd George’s Government, was up for reelection as a Member of Parliament representing Dundee (Scotland), his appendix reared its infected head. Churchill consulted his doctor, Thomas Crisp, complaining of a weeklong bout with abdominal pain. The surgeon quickly diagnosed acute appendicitis and just as quickly operated that same evening, a decision that “proved timely as his notes record that the appendix was gangrenous, as well as perforated.” Coming out of the anesthesia, Churchill, ever the politician, is said to have demanded, “Give me a newspaper.” Crisp quieted him, left the room, and returned a few minutes later to find Churchill lying unconscious under a cover of newspapers. At the time, surgery was far more complex and wearing than it is today, when laparoscopy and safer anesthesia often make appendectomy a walk-in-walk-out procedure, so Churchill was sent to recuperate in a nursing home, while his wife went off to face the voters who were none too fond of Winston. Two days before the vote, campaigning in a wheelchair, he took her place in front of a group of voters about whom he said, “but for my helpless condition, I am sure they would have attacked me.” In the end he lost, scoring barely 15 percent of the total vote. Churchill was out of Parliament for the first time since 1908, and at year’s end, he famously pronounced himself “without an office, without a seat, without a party and without an appendix.” And he had one other complaint, the “horrible affliction” of having to swear off alcohol at lunch “to improve his digestion.” Thomas Crisp was a man who honored the confidentiality of his patients’ health, so the drama of Churchill’s unruly appendix remained a secret for twenty-seven years until after Crisp died in 1949.29, 30

  FORM FOLLOWS FUNCTION

  On February 9, 1926, a dozen historically minded young Kentucky physicians met to form the Innominate [“no name’] Society of Louisville. Their aim was to present and discuss unusual and interesting moments in medical history and the cultural aspect of medicine itself. Each spring, the Society invited an expert in to address the group. In 1927, the man at the podium was Arthur C. McCarty, M.D., Professor of Medicine at the University of Louisville. His topic was the appendix.

  “The uses of the appendix are a history as complex as its name,” he announced. “Fallopius, writing in 1561, appears to have been the first writer to compare the appendix to a worm; and [Swiss physician, anatomist, and botanist Gaspard Bauhin (1560–1624)] the first in 1579 to ascribe thereto a function. He proposed the ingenious theory that the appendix served in intrauterine life as a receptacle for the faexes [feces]; from which it seems not improbable that he confounded it with the diverticulum described nearly two hundred years later by Meckel, whose name it bears … [others] to be conjured with, added more or less insignificant ideas concerning the structure of the appendix and entered upon useless controversy concerning the name, function, position, etc., of the appendix vermiformis.”31

  Dr. McCarty’s historiography was interesting but slightly off the mark. Gabriele Falloppio (1523–1562), the Italian anatomist who named the Fallopian tubes, may or may not have been the first to write the “worm” next to the word “appendix,” but the Egyptians said it first, and the Swiss physician, anatomist, and botanist Bauhin was certainly not the first to suggest it was somehow useful. On the other hand, McCarty’s general assessment of the confusion surrounding the form and function of the appendix was accurate to a fault.

  Every age has its own beliefs and prejudices, particularly when it comes to the human body. Hippocrates said many wise things, including the direction to “Let food be thy medicine and medicine be thy food.” But when it comes to Big Ideas, perhaps his biggest was that notion endorsed by his contemporaries and medical men right up to the Renaissance that good health depended on vital air (pneuma) and a balance among the drops of elements in the body. These elements, known as the four humors — yellow bile, black bile, phlegm, and blood — were each linked to a season of the year, an item in the environment, a measure of temperature and moisture, and last but by no means least a psychological condition:

  • Yellow bile = summer, fire, hot and dry, characterized by a hot temper.

  • Black bile = autumn, earth, cold and dry, characterized by melancholy.

  • Phlegm = winter, water, cold and moist, characterized by a calmness.

  • Blood = spring, air, hot and moist, characterized by passion and optimism.

  Today, we have a different list of Big Ideas on Health, shorter by half. No one can guarantee what medicine will say tomorrow, but right now, as you read this page, by popular consensus the two things most likely to improve your chance of staying healthy are a healthful diet and a top-notch immune system. And each has been—one correctly the other not so much—linked to your appendix.

  Your appendix and your diet. Given the appendix’s physical attachment to the digestive system, the natural assumption has often been that it has something to do with food and nutrition. Perhaps animals such as humans who lack the enzymes required to extract nutrients from the insoluble dietary fiber in, say, hay and grass need an appendix to do the extra work of digesting plant food. That might explain why we have an appendix and cows don’t and why Darwin thought that the human appendix might have lost its reason to live when we cut back on roots and leaves and added meat to our menu.

  In 1925, the first person to suggest that appendicitis might be a “disease of Western civilization” linked to a low-fiber diet was Arthur
Rendle Short, professor of Surgery at Bristol University (UK). But the first proper though accidental medical observation of a link between dietary fiber and the appendix may have occurred in a small town in Burma in late 1946 and early 1947 where two British doctors were serving at a Casualty Clearing Station near a camp with Japanese soldiers waiting to be sent home. The Japanese soldiers had their own doctors, but surgical cases were referred to the British facility, where, it turned out, approximately one case of appendicitis turned up every two or three weeks. “We were intrigued by the high incidence of appendicitis in the Japanese soldiers,” one of the British doctors reported nearly half a century later, “and thought it might be because the camp was receiving mainly British rations which had a lower fibre content than the normal diet of a Japanese soldier. The fact that their own medical officers were surprised at the number of cases suggested that appendicitis was normally rare in Japanese troops. Fortunately, in the [same] area there were large concentrations of Indian, Gurkha, and Burmese troops, and a battalion of irregulars from the Chin Hills, on the border between Burma and what is now Bangladesh. The total number of these troops greatly exceeded the number of Japanese soldiers in the camp, yet we admitted no cases of appendicitis from these various nationalities.” Furthermore, the authors noted, “Appendicitis was 4–6 times more common in the British than in the Indian troops [in India during the period 1936–1947]. In the same period, the basic ration for Indian troops contained one third the amount of animal protein and three times as much high fibre foods (parboiled rice, atta [unrefined wheat flour], and pulses [dal and peas]) as that of British soldiers in India.”32

  The notion of a link between a high-fiber diet and a lower risk of appendicitis and, soon after that, colon cancer, slumbered along, picking up advocates here and there until 1979. That year, Denis Burkitt (1911–1993), an Irish missionary surgeon, noticed that Africans who consumed a diet rich in food fiber had a lower incidence of colon cancer than their “more advanced” counterparts around the world. He published his observations in a small book called Don’t Forget Fibre in Your Diet.33 It immediately became an international best seller. Two years later, Burkitt and his fellow physician-missionary Hubert Carey Trowell (1904–1989) published Western Diseases: Their Emergence and Prevention, once again stressing the protective features of a high-fiber diet.34 (For the record, it should be noted that Burkitt had a second, less well-known theory of how to reduce the incidence of gastrointestinal problems. He believed that squatting to defecate, as one did in communities without toilets, was protective.)35