EARLY SURGICAL INTERVENTIONS FOR APPENDICITIS IN RHODE ISLAND
The surgical treatment of appendicitis was largely an American success, when antisepsis and anesthesia made surgery a practical mode of treatment. Vigorous debates and adoption of new procedures were just as conspicuous in Rhode Island as elsewhere in the nation. Given the importance of the disease in American medicine, there is a lack of attention to appendicitis in Rhode Island’s medical and surgical history.
Dr. George L. Collins performed the first appendectomy at Rhode Island Hospital in 1893. Articles by Drs. Donald Churchill and John W. Keefe elucidated the struggle of the state’s physicians and surgeons to understand the anatomy of the vermiform appendix, the natural history of the disease, and the most effective treatment. Appendicitis received some attention in the History of the Rhode Island Medical Society in 1966.’ In 2001, Drs. Hopkins, Bowen, and Francis surveyed the history of surgery in Rhode Island, but allowed only a few lines for the early surgical management of appendicitis.2 This historical record requires completion.
A Rhode Islander, Dr. Robert F. Noyes, published an article in 1882, which influenced the classic 1886 article by Dr. Reginald H. Fitz, of Harvard. “These two remarkable monographs,” wrote Dr. Walter L. Monro in 1935, “played the major role in establishing the identity and pathology of the disease and opened the floodgates for the greatest and most widespread torrent of surgery the world has even seen.”3
THE EARLY PAPERS
From 1833 until the mid-1880s, the Frenchman, Dupuytren, was the eminent surgical authority on lower right quadrant pain. According to Frederick F. Cartwright, in The Development of Modern Surgery, Dupuytren had convinced physicians that pain and abscess occurred more frequently on the right side than on the left because of a valve in the portion of the large gut, the caecum, to which the appendix is attached. He also declared that no structure so insignificant as the appendix could possibly cause such disastrous and wide-spreading effects. “Dupuytren therefore supported the terms ‘typhlitis’ and ‘perityphilitis’, inflammation of and around the caecum (typhlon being the Greek variant of the Latin caecum). Dupuytren’s weighty opinion did much to confuse the issue and to hold back advance.”4
Dr. Job Kenyon, president of the Rhode Island Medical Society, enlisted his former student, Robert Noyes, to report on perityphlitis. Noyes based his report on one hundred surgical cases from The New York Hospital between 1843 and 1882, since he found only a few recorded cases in Providence. On December 21, 1882, Noyes told the Society that there was a “heterogeneous distribution” in the medical literature on perityphlitis, meaning that little agreement existed about the nature of inflammation in the right iliac region; yet these cases were always “important and anxious.” He concluded that a differential diagnosis between perityphlitis and appendicitis “may well nigh be impossible.”5
Rhode Island physicians didn’t forget the significance of Noyes’ contribution. “I have often thought,” Keefe mused in 1915, “that that master of medicine, Dr. Fitz, may have been stimulated on reading Noyes’ paper to produce his epoch-making paper on appendicitis in 1886.” As late as 1966, in The History of the Rhode Island Medical Society and its Component Societies, 1812-1962, Wilfred Pickles noted that Noyes “foreshadowed” the work of Fitz, who “repeatedly gave credit to Doctor Noyes for his help in bringing this about.”6 Over a century later, in 1992, seebert Goldowsky wrote of Noyes: ‘He was aware of the not infrequent association of appendiceal perforation with the condition, but the implications of this eluded him, as it had practically all of his contemporaries.”7
In 1886, Reginald H. Fitz, a pathologist, made the decisive connection between right iliac fossa inflammation and appendiceal perforation, and coined the term appendicitis. After a review of 466 cases, Fitz openly challenged Dupuytren’s ideas: “As a circumscribed peritonitis is simply one event, although usually the most important, in the history of inflammation of the appendix, it seems preferable to use the term appendicitis to express the primary condition.” Fitz further noted the importance of early recognition of the perforating appendix and the urgent demand of treatment, according to surgical principles.8
Not surprisingly, physicians distrusted an academic pathologist such as Fitz, and had little use for surgeons, whom they considered ambitious, if not downright dangerous. Following Dupuytren, they continued to treat the caecum with medicine, hoping for a resolution. A few still employed bloodletting and administered various kinds of enemas, practices not advocated since the 1830s. A Doctor Richards sought advice from the members of The Providence Medical Society in 1888: “One doctor suggested the use of leeches and poultices, while three were against operation and three were in favor of operation. There is no mention made of the final course of therapy in this instance; most probably it was conservative.”9
John W. Keefe, then a young surgeon in private practice, reported on appendicitis before the Rhode Island Medical Society on December 10, 1891. He cited the English surgeon, Sir Frederick Treves, who noted in 1885 that the caecum was entirely covered by peritoneum. Keefe argued that “the leading surgeons of the day are now agreed that these abscesses are intro-pentoneal, being walled off from the general peritoneal cavity by recent adhesions of intestinal and parietal peritoneum, due to the localized peritonitis which is always present.”10
Keefe cited Charles McBurney, a fellow New Engländer, whom he had known from his days as an intern at Bellevue Hospital, New York City. Although not historically accurate, McBurney s name is associated with the classic diagnostic sign for appendicitis: “The exact locality of the maximum tenderness, when one examines with the fingertips in adults is one-half to two inches inside the right anterior spinous process of the ilium on a line drawn to the umbilicus…. I have demonstrated in every case operated upon by me, since I first made the observation.”” Kecfe’s emphasized that McBurney s sign could be clearly demonstrated from the first hour of the disease. 12
Noyes supported Keefe’s zeal for surgical intervention, yet showed less enthusiasm for the idea that pus formation and pain in the right iliac region were due to the appendix. In his mind, typhlitis and perityphlitis actually did exist. “Therefore I cannot accept the statement that every case of so called perityphlitis should be regarded as primarily an inflammation of the appendix vermiformis.”13 In a view remarkably conservative for Noyes, he said the clinician can only “wait and watch, hoping for resolution, but fearing suppuration. An inflamed and ulcerated caecum might involve the appendix only secondarily.”14
A few years after his first paper, Keefe described twelve “consecutive and successful” operations he performed for appendicitis. “More has been written upon the etiology, pathology and treatment of appendicitis during the last five years than upon any other disease. Keefe cited W.T Bull, of New York, who found that the mortality rate was 40.67% for patients treated without operation. In contrast, the mortality rate for cases treated by the Willard Parker operation was 15%, especially if performed within the first three days of the disease. “I am fully convinced,” Keefe wrote, “that the early operation by a skilful surgeon, will save the greatest number of lives.”15 Even the daily press, he wrote, has taken up the subject with more or less correctness. It was becoming a “fashionable disease.”16
THE FIRST SURGURIES
On March 6, 1901, Donald Churchill, House Surgeon at Rhode Island Hospital, read a paper on appendicitis at Rhode Island Hospital between 1891 and 1900. Churchill reviewed twenty cases, two of which deserve special attention. The first took place on the afternoon of March 4, 1891. In the crowded operating room, nine physicians observed George L. Collins perform the Willarcl Parker Operation on a nine-year old child diagnosed with a perityphlitic abscess. Collins made an incision in the right iliac region through the first two muscular layers, introduced an aspirating needle and withdrew “very fetid pus.” A second incision exposed more pus, and a counter incision allowed a rubber drainage tube to be pulled through.
Following a difficult post-operative period, the child went home early in the month of June. This case, noted Churchill, was the first one of “operative interference … and it marks an epoch in the history of the hospital.”17
Two years later, on February 6, 1893, two general practitioners, Dr. Carr and Dr. G.S. Matthews, admitted a young English silversmith to Rhode Island Hospital, following three days of pain in the right lower part of the abdomen. A simple note opened the clinical record: “Operation Feb 6th, 1893 by Dr. Collins, assisted by Dr. Keefe.”18 This time the appendix was drawn up to the surface of the wound, ligated with catgut to close its junction with the intestine, and removed. The patient recovered and was discharged on March 18th. Increasingly, surgeons gained confidence, optimistic that their position would gain acceptance and their faith in operative principles would be vindicated. Churchill strutted: “.. .It has been clearly proven that appendicitis is a surgical disease, and surgeons of large experience have come to the conclusion that in the long run they will save more lives by operating on all cases, with very few exceptions, as soon as the diagnosis is accepted.”19
John W. Keefe, born in Worcester in 1863, came to Rhode Island Hospital as a surgical extern in 1886. Ambitious and skilled, he quickly gained recognition throughout the state, and in 1915 established the John W. Keefe Surgery, a private surgical hospital on Blackstone Boulevard.
Keefe believed that appendicitis required immediate surgical action. Following McBurney, Keefe condemned the use of an aspirating needle to drain pus from the abdominal cavity: “It may do harm in passing to or from the pus cavity, and should pus not be found by its use, it by no means proves that it is not present…. The more skillful the surgeon the less frequently he uses the aspirating needle.”20 He didn’t criticize the Willard Parker operation, in which the abscess was drained, yet, appealing to McBurney, he preferred for the early removal of the appendix: “This operation by removing the primary cause of the trouble cuts short at once a disease which threatens life.”21
By 1915 Keefe noted the “remarkable progress” since the mid-1880s, suggesting that “no one in these modern times should die from appendicitis, and would not, if they were operated upon sufficiently early.” Before a national medical meeting, Keefe impatiently chided the medical profession and the laity, charging that the illtimed advice given by physicians often resulted in too many deaths due to appendicitis. Keefe railed:
“How often do we hear it said: Oh, it is simply a case of intestinal indigestion due to something you have eaten. Take a good dose of castor oil and you will be all right in the morning.’ There are many physicians today who do not realize how many patients have they laid in their graves by this, seemingly, innocent advice. The free administration of opiates in the early stages of the disease frequently mask symptoms and give the physician and patient a false sense of security, causing the loss of valuable time and frequently of life….I have observed that an intern who, while serving in a hospital, will invariably urge immediate operation at any time, either day or night; will yet, when he enters private practice, be swayed by the family, or perhaps by other reasons, to postpone operation, prescribe opiates and cathartics and wait for further developments.”22
Keefe chided those who ignored the literature on the natural history of the disease and its treatment: “Don’t kill patients, the victims of appendicitis, with cathartics,” he said. “Make the diagnosis early. Advocate operation before the end of the first day and see to it that a man well qualified to do the surgery performs the operation.” 23
Medical historian Dale C. Smith believes surgery of the appendix became both paradigm and prototype of general surgery in twentieth century America. First, operative treatment for appendicitis served as a “window into the emergence of surgical therapy as the twentieth century began; second, the recognition of appendicitis as a surgical disease was “a major step in the transformation of the public and professional understanding of surgery’s place in medicine.”24
Smith notes that by the 1920s widespread agreement prevailed in American medicine concerning the appropriateness of surgical referral or consultation for appendicitis: “The diagnosis seems to have been made with more unanimity…. With the increasingly common limitation of practice to the specialty of surgery, the general practitioner did not have to fear referring the patient.”25 Rhode Islanders can be proud of the contribution of Noyes, Collins and Keefe to the surgical treatment of appendicitis. They led the way toward better management of this dangerous disease.
1. Pickles W. The History of the Rhode Island Medical Society and Its Component Societies, 1812-1862. East Providence, Roger Williams Press, 1966:70-2.
2. Hopkins RW, Bowen JR, Francis WW. Arch Surg 2001 ; 136:461 -6.
3. Monro WL. RI Med J I935;july:138.
4. Cartwright FF. The Development of Modern Surgery. NY: Thomas V. Crowell, Col: 1967:204.
5. Noyes RF. Tram RI Med S 2. Providence, RI Medical Society, 1877-1882:494-539.
6. Pickles, of.cif.68.
7. GoldowskySj.RIMed 1992;75:547.
8. Fitz RH. Trans Assoc Amer Physicians, First Session: 107-44.
9. Wing ES, WingJR. cited in Pickles, op.cit:174.
10. Keefe JW. Trans of the RI Med Society. 1889-1893; 4:288-311. This paper was read to the Society on December 10, 1891.
11. McBurney C. NYMedJ 1889;50:676. McBurney was not the first surgeon to indicate the classic diagnostic sign or the first to use the incision. In 1 899 J.B. Murphy of Chicago described the classic signs; in 1884 L.L. McArthur of Chicago developed the technique. Yet McBurney received the honors.
12. Keefe, op.cit: 303.
13. Noyes, op.cit: 315.
14. Ibid: 321.
15. Keefe, op.cit: 561.
16. Keefe, ibid: 548.
17. Churchill D. RI Med J 1901 ;2:93.
18. Collins GL. Tram of the RI Med Society 1889-1893: 546-7.
19. Churchill, op.cit: 93.
20. Keefe, op.cit: 306.
22. Keefe. Am J Obstet Dis of Women and Children 1915:72:1-6.
23. Ibid, 6.
24. Smith D. Bull Hist Med 1996;70:441.
FRED ARSENAULT, MS
Fred W. Arsenault, MS, an amateur historian, is a laboratory technician in the chemistry department of the Eleanor Slater Hospital laboratory.
Fred Arsenault, MS
12 Johnson Avenue
Warwick, RI 02886
Phone: (401) 737-7801
Copyright Rhode Island Medical Society Dec 2004
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