The human vermiform appendix

A general surgeon’s reflections

First published:
TJ (now Journal of Creation) 3(1):31–38
April 1988

by J. Warwick Glover

The Year 1986 Was

i. the 250th anniversary1 of the first successful removal of the appendix (appendectomy)
and
ii. the 100th anniversary2 of the word ‘appendicitis’ (inflammation of the appendix) being
used in the surgical literature.

The Disease
Acute appendicitis, although on the decline again, still looms large in the everyday life of a
surgeon. It is still by far the commonest cause of a patient presenting with an acute abdomen.
Although the results of treatment have improved dramatically in the past 75 years, generally
reflecting the great advances surgery has made in that time, there is still a morbidity and
mortality that cannot be considered insignificant.2,3,4 The present decline in incidence of the
disease is possibly due to recent improvements in the previously deteriorating diet of Western
civilisation (Rendle Short,5 Burkitt6).

The Organ—Macroscopic2,7,8,9,10
The appendix is commonly referred to as a classic example of a vestigial organ. Such a
statement implies that the appendix represents a vestige of an organ with a former greater
existence in the evolutionary sense, rather than in an earlier stage of its development.

It was because of Charles Darwin’s ‘Descent of Man’ (1871)11 in fact, that the vermiform caecal
appendage became widely regarded as a rudimentary organ representing the much more
developed distal caecum present (if evolution is assumed) in man’s more herbivorous ancestors.

Darwin’s Argument
Darwin’s argument about the appendix being vestigial was incorrect in his application of:

i. homology, and
ii. Lamarckian inheritance.
Darwin and Homology

When he based his ideas concerning the organ’s function on homology, Darwin erred by:

a. regarding the caecum and appendix as part of the same unit organ, structurally and
functionally, rather than (albeit in continuity) separate structures with different functions,
b. comparing the unit between different animal kinds, assuming similar functions of the
complex, with emphasis on organ functioning being directly proportional to its size, and
then
c. inferring the appendix is a rudiment in man on account of its small size and variability!

In thus making his comparison, he thus assumed evolution to explain the interpreted
regression, but later argued that it was this regression that was later good evidence for
evolution—a circular argument.

Darwin and Lamarckian Inheritance

Once Darwin erred in assuming that function declines with size, he erred further in assuming:

a. the mechanism for this decline was disuse, and that

b. such an interpreted regression was inheritable, that is, successive generations acquire the
characteristic of a smaller and smaller caecum and appendix and transmit this
characteristic to their offspring.

This type of inheritance, or should we say disinheritance, according to disuse is distinctively

Lamarckian (even admitted by Ruse12 in his ‘Darwinism Defended’, p. 43) and such a mode of
inheritance has long been discarded as it contradicts our basic understandings of Mendelian
genetics.

Darwin’s Influence
After Darwin said the appendix was vestigial and useless, he and others went on to suggest it was
more susceptible to disease. This propensity for the appendix to be diseased, and possibly
dangerously so (‘Descent of Man’, p.27), is in no way due to the organ having a lowered vitality
and tending towards an atrophic (wasted) defenceless state, but simply a consequence of one of
its functions placing it in the body’s front-line in the battle against infection. Akin to the tonsil
guarding the upper alimentary tract from bacteria etc., so does the appendix guard the entrance
from the almost sterile ileum into the normally bacteria-infested colon (see Fig. 1).
Figure 1. Sketch of the human vermiform appendix and its
location at the apex of the caecum below the entrance of the
ileum.

Later still, Darwinists suggested the ready dispensability of the appendix proved its uselessness.
This type of logic would have a daughter believing her mother’s womb was useless if her mother
was unaffected after a hysterectomy in later life for a disease of the uterus.

The Organ -Microscopic2,7,8,9,13,14

Present day histology textbooks are starting to acknowledge that the appendix with its
complicated and rich blood supply and marked tissue differentiation is a complex and highly
specialised organ. Of course, the histological appearance of the appendix has been exactly the
same all the time, but people are now starting to look at it from a different perspective.

The most recent edition of ‘Gray’s Anatomy’9 indicates in its embryology section that the
appendix is a vestigial remnant indicative of man’s ancestors’ more herbivorous dietary habits,
whereas the anatomical section says, ‘In view of its rich blood supply and histological
differentiation, the vermiform appendix is probably more correctly regarded as a specialised than
as a degenerate, vestigial structure. The configuration of the caecum and appendix in man and
the anthropoid apes, is probably less primitive than in the monkeys.’9 Surely one can’t have it
both ways!

From what has been said so far it can be seen that whereas in the past it was considered the
appendix was becoming vestigial (involution with evolution), it is now generally accepted that
the appendix is a highly specialised, well-differentiated organ apparently developed to the
maximum in its specialisation in man.

Comparative Mammalian Alimentary Tracts And Digestive

Processes.2,7,10,15,16,17
A careful examination and comparison of aspects of digestion in several kinds of animal is now
in order.

Rabbits

The rabbit gains amino acid nitrogen and other nutriments from the bacteria which digest the
cellulose from grass etc. in its large caecum. The rabbit passes two types of stool; the one which
is mucus-coated the rabbit eats (coprophagy), recycling it through the intestine to allow for
absorption of the bacteriolytic products of grass digestion. Few animals would eat more grass
than a rabbit, yet although it has a very large caecum acting as a fermentation tank, it also has a
sizeable and distinctive appendix containing lymphoid aggregations in its wall.

Ruminants

With cleft hooves, the ruminants such as cows, sheep and goats have a four-chambered stomach
and gain many of their nutriments from the bacteriolytic digestion of cellulose in the rumen
chamber of their stomach after regurgitation many times to improve the mix-chewing the cud.
The ruminant digestive mechanism also allows for some recycling of urea into the saliva for
bacteria to utilise, as well as the bacteria converting the plant cell amino acids into its own type
which are more akin to what the cow, for example, requires. These animals have a seizable
caecum for additional bacterial fermentation to occur, but no appendix.

Horses

The horse has a more human-like stomach and gains nourishment by absorbing similar by-
products of the bacteriolytic digestion of cellulose, as do most herbivores possessing such
cellulase-producing bacteria in their gut. But the main absorption site of such products in the
horse is through its very coiled and redundant caecum and colon. Once again the bacteria convert
plant amino acids etc. to the preferred animal types. However, the horse does not have an
appendix.

Dogs and Cats

Dogs and cats favour a mixed-to-carnivorous diet (or CAN-ivorous in domestication!) and obtain
most of their nourishment from absorption of products of food digestion by their own small
bowel juices, not unlike man. They have a bigger caecum than man where some bacterial
fermentation occurs, but no appendix.

Monkeys
Whether so-called ‘New World’, or ‘Old World’, monkeys do not have an appendix. Eating
more nutritious food, such as fruit and nuts, their digestion is aided to a greater degree by their
own digestive juices, so that more absorption occurs higher in the alimentary canal. They have a
caecum which is not terribly big, so it has been compared to the embryonic stage of the
developing human caecum and appendix unit. But of course, if we were to follow this line of
argument, we would have to say the appendix, rather than becoming rudimentary and
disappearing, is appearing and developing as we ascend the supposed evolutionary scale. This
raises other difficulties.

Anthropoid Apes and Man

The anthropoid apes (gibbon, orangutan, chimpanzee and gorilla) and man also have a small
caecum but with a distinctive terminal appendix (see Fig. 1). Although they eat a mixed diet,
they are predominantly herbivorous, but the bacteria in their caeca do not secrete cellulase. the
necessary enzyme for cellulose degradation and digestion. Nourishment is mainly from the
absorption of food breakdown-products resulting from their own digestive-juice actions in the
small intestine not dissimilar from digestion and absorption which occurs in monkeys, cats and
dogs.

Thus considering the digestive processes and absorption areas in several representatives of the
animal kingdom, we see similarities and differences—mosaicism18,19 in the use of plan and
purpose among animal kinds and discontinuity between animal kinds. The appendix, as a
distinctive organ separate from the caecum, has been present and absent among the above
examples.

Only A Few Diverse Mammals Possess An Appendix2,7,10,17

In a study of the alimentary tracts of animals we find the appendix is not present in any
invertebrate. Among the vertebrates, it is absent in fish, amphibians, reptiles, birds and most
mammals. In fact, the vermiform appendix, recognised as a worm-like, narrow extension
beginning abruptly at the caecal apex (see Fig. 1 again) is only present in a few marsupials such
as the wombat and South American opossum, a few rodents (rabbits and rats) and few primates
(only the anthropoid apes and man). Note that monkeys do not have such an organ.2,7,10,17

Taking any evolutionary tree an evolutionist cares to suggest, and trying to correlate the
appearance and disappearance of the appendix with such a tree, is impossible. A typical defence
is either to argue that soft parts don’t fossilise and things must have been different in the past
(evolutionists then ignoring their cherished axiom ‘The present is the key to the past’), or calling
upon ‘convergent evolution’, which is a type of explain-anything phrase without mechanism that
is frequently used to defy the above obvious type of mosaicism.

The Evolutionist Has A Mammoth Problem

If formerly the evolutionist had the appendix going and now has it coming, he cannot explain
why it is first present in some marsupial animals like the wombat, but absent in all the mammals
between the wombat and apes and man, apart from the rabbit and a few rodents, and especially
explaining the absence in monkeys.

Evolutionary postulations would have us believe that a tailed mammal without an appendix gave
rise to a monkey with a tail but still without an appendix, which then gave rise to an ape without
a tail but with an appendix, and then on to man where the appendix has developed to the
extreme! Although an oversimplification, the above exemplifies the incredible problem the
evolutionist now has with his supposedly vestigial appendix. With one argument he has us
believing it’s going and with the other it’s coming. Perhaps it is neither going nor coming.

The Creationist Viewpoint

The fiat creationist would expect various kinds of animals to have alimentary tracts based on a
common design, with modifications and specialisations on that basic blueprint being made in
appropriate areas.19 Such alterations would still be according to plan and purpose, and
conforming to the structural and functional needs of the organism in question in its natural
environment. The organism would also have an inbuilt ability to adapt within a fixed range to
allow for growth to maturity and adjustment to environmental variations. The caecum and
appendix, when viewed as separate but related specialised entities in structure and function in the
digestive tracts of different animal kinds, do not contradict creationist expectations.

Functions Of The Human Appendix2,4,7,8,20,21

The appendix completes most of its functions at the early end of the spectrum of life. The
vital aspects of these are probably complete at least by early infancy. While it is freely admitted
that the precise functions of the human vermiform appendix are still unclear, so much more is
now known that clarification is at hand. It is my intention to discuss this further under the
following headings:

1. Embryological
2. Physiological
3. Microbiological (Bacteriological)
4. Biochemical
5. Immunological

1. Embryological2,22

During the fifth foetal week it is the appendix which develops from a bud at the junction of the
small and large bowel and undergoes rapid growth into a pouch. In the sixth week there is a
transient nubbin surmounting the pouch indicative of being involved in the rapid development of
the pouch which is very strategically placed near the apex of the highly significant mid-gut loop.
It is only after the fifth foetal month that the proximal end of this pouch, which has appeared to
be a very insignificant structure up until this stage, starts growing differentially to give rise to the
true caecum which continues to develop into infancy.
 The embryonic appendix has finger-like projections (villi) on its inside surface and it is only
around birth that the long ribbons (taeniae) causing the sacculation of the large bowel start to
develop. These ribbons, of course, converge on the base of the appendix.

2. Physiological2,23,24,25

The goblet cells lining the appendix and adjacent caecum and colon secrete a special type of
mucus which can be regarded as an antibacterial paint controlling the organisms which develop
in the bowel in the region. The paint contains a high concentration of IgA type immunoglobulins,
secretory antibodies produced for mucosal or surface immunity and part of the bowel-blood
barrier .

3. Bacteriological2,23,24,25

Through the cells within and overlying the lymphoid follicles and their production of secretory
and humoral antibodies the appendix would be involved in the control of which essential bacteria
come to reside in the caecum and colon in neonatal life. As well it would be involved in the
development of systemic tolerance to certain antigenic agents within the alimentary tract whether
they are derived from bacteria, foodstuffs or even the body’s own proteolytic enzymes.

4. Biochemical2

One in three hundred or so appendectomy specimens contains a carcinoid tumour composed of a

highly specialised type of cell rich in vaso-active peptides such as serotonin. The exact function
of such agents in the entire bowel is still being elucidated, but the fact that the majority4 of such
tumours occur within the appendix is indicative that the appendix could well be involved in some
way with such substances.

5. Immunological2,4,9, 13,14,20,2.1,23,25,26,27,28,29

This is the area where the appendix would seem to have its predominant functions due to its
content of lymphoid follicles, which are highly specialised structures. Although it was thought
the appendix itself could be the site for B-lymphocyte induction (a Bursa of Fabricius
equivalent)26 the latest opinions favour this programming being more centralised in the bone
marrow. The appendix may still have a role in this highly significant function, but not alone, and
its lymphoid tissue is known for certain to be involved in antibody production (the function of B-
type lymphocytes). These antibodies are of two types:

i. IgA type immunoglobulins for secretory or mucosal surface immunity, and

ii. IgM and IgG immunoglobulins for humoral or bloodstream immunity.

The above type functions have proven the appendix to be part of the G.A.L.T.2,4,23,25 (Gut
Associated Lymphoid Tissue), but it has also been shown that the appendix after the neonatal
period is dispensable, meaning that normal G.A.L.T. functions remain after appendectomy. This
result is not unexpected as similar lymphoid tissue is distributed up and down the alimentary
tract, there being a considerable reserve potential. Experiments in rabbits have shown that the
appendix alone can provide normal humoral antibody levels if necessary27 and also replenish
depleted lymphocyte populations secondary to neonatal thymectomy.28

These results have been in rabbits, and the rabbit appendix is not exactly the same as the human.
Studies of the functions of the human appendix, however, have tended to concentrate on
extrapolating across from animal models where it is difficult to escape evolutionary overtones
and possibly repeating the errors Darwin made when using homology.

Other studies on the human appendix have tended to concentrate on tissue from young adults
when the appendix has probably completed its major role. Recently the topography14 of immune
cells and their products in the appendix have been described both in the presence and absence of
acute inflammation, as well as it becoming evident that lymphocytes individually move into the
appendix between the tenth and twentieth foetal week.14 Such studies have also highlighted the
mode of immune cell reactions both with each other and other cells in the area in a detail not
known before and quite significant advances have been made. Of course, lymphoid follicles do
not actually appear as such in the appendix until two weeks after birth4 at the same time that
colonisation of the large bowel with bacteria which are safe to their host begins. The follicles
increase steadily in number to a maximum of two hundred at about fifteen to twenty years of age
and decline back to about one hundred by thirty years of age and decline further, even to
disappearance, throughout the rest of life. The peak incidence of acute appendicitis coincides
very well with the peak number of lymphoid follicles and their enlargement with infection,
whether it be initially viral or bacterial, probably contributes significantly to the luminal
obstruction29 so important in the initiation of acute appendicitis.

In the past decade we have increased our knowledge considerably of the cells lining the
gastrointestinal tract, especially in the small bowel and ileocaecal region, where new hormones
and their functions have been discovered and so have received a lot of attention in appropriate
journals. Clarification of B-lymphocyte induction9,13,26 and topography of the cells in foetal and
neonatal appendiceal tissues is awaited with interest.

In summary therefore, the human vermiform appendix appears to be a complex and organised
structure both in its development and maturation, and almost certainly has corresponding
complexity in its functions which, like most gastrointestinal functions, are still awaiting further
clarification. It would appear that the functions of the appendix would be most important when
the organ itself has most prominence, and this is in the developing foetus and early existence
after birth. The inside of the bowel is outside the body and the area where substances foreign to it
have their greatest chance of attack. The appendix appears to be strategically placed and
structurally composed of tissues which are vital in establishing and maintaining the various
types of body defences or immunity necessary in recognition of such assaults and having a part
to play in their repulsion. The appendix is thus one of the guardians of the internal environment
of the body from the hostile external environment.

Conclusions
The vermiform appendix occurs only in a few diverse mammals.10 This supports the view that
among animal kinds with respect to the occurrence of such a particular and specialised feature
one sees mosaicism in its distribution with discontinuity between animal kinds. A careful
assessment of the embryology of the appendix in humans indicates that quantitatively it has a
very early and rapid development during the critical stages of bowel growth and organisation.
However, microscopically the tissues of the appendix are complicated and highly specialised, but
this qualitative aspect of the organ’s growth does not occur until just after birth when the
neonate takes on essential bacteria to reside in its colon.

The appendix would appear to have a role (although not as the sole organ) in establishing and
maintaining the bowel-blood barrier for such bacteria in its area. The special aspects of the
mucus produced in this area (the antibacterial paint-like action) along with the appendix figuring
in the development of its region have been discussed. It has also been shown that the appendix
can in no way be vestigial in an evolutionary sense. The hallmarks of the appendix thus appear to
be creative design and organisation as if it is formed according to a plan to play a specific
purpose. If one studies any organ or organism in the living world, one comes across such a
discontinuous and mosaic distribution of structural and functional features among animal kinds.
The features for structure and function go hand in glove with each other, obeying sound
principles of design engineering and organisation yet possessing incredible functional capacities.
Notwithstanding such features, there is also an economy of effort to achieve them and within the
system an inherent beauty. Such studies speak of an all-wise Great Architect having dominion
over His every creation, be it big or small, fat or thin, so that no one can deny we are ‘fearfully
and wonderfully made’.

Recommended Resources
References
1. Williams, G.R., 1983. A history of appendicitis. Ann. Surg., 197:495f.
2. Glover, J.W., 1984. The appendix revisited. Proceedings of the Provincial Surgeons of
Australia 20th A.G.M., pp.1-5.
3. Maingot, R., 1974. Abdominal Operations, Appleton-Century- Crofts, 6th edition, Vol.
2, p. 1350f.
4. Schwartz, S., 1984. Principles of Surgery, McGraw-Hill, fourth edition, p.1245f.
5. Rendle Short, A., 1920. Br. J. Surg., 8:171f. (Arthur Rendle- Short, 1880-1953, was the
father of the present chairman of Creation Science Foundation, Professor John Rendle-
Short. He wrote on appendicitis and diet in this classic 1920 paper.)
6. Burkitt, D.P., 1971. The aetiology of appendicitis. Br. J. Surg., 58:695f.
7. Kelly, H.A. and Hurdon, E., 1905. The Vermiform Appendix and Its Diseases, W. B.
Saunders, Philadelphia.
8. Robbins, S.L. and Cotran, R.S., 1979. Textbook of Pathology. Saunders, second edition.
9. Williams, P.L. and Warwick, R., 1980. Gray’s Anatomy, Churchill Livingstone, 36th
edition.
10. Berry, R.J.A., 1900. The true caecal apex, or the vermiform appendix: Its minute and
comparative anatomy. J. of Anat. and Physiol., 35:83f.
11. Darwin, C., 1871. The Descent of Man, J. Murray, London; esp. pp.17-33.
12. Ruse, M., 1982. Darwinism Defended, Addison-Wesley.
 13. Wheater, P.R., Burkitt, H.G. and Daniels, V.G., 1982. Functional Histology: A Text and
Colour Atlas, Churchill Livingstone. ELBS edition.
14. Tome, V.A. and Retief, F.P., 1978. Human vermiform appendix, Immunocompetent cell
topography and cell to cell interactions in situ. J. of Immunolog. Methods, 20:333f.
15. Wilson, E.O., Eisner, T., Briggs, W.R., Dickerson, R.E., Metzenberg, R.L., O.Brien.
R.D., Susman, M. and Boggs, W.E., 1978. Life on Earth -Biology Text, second edition.
16. Curtis. H., 1984. Biology, Worth, fourth edition.
17. Kavanagh, M., 1983. A Complete Guide to Monkeys, Apes and Other Primates, Cape.
18. Denton, M., 1985. Evolution: A Theory in Crisis, Burnett, London.
19. Parker, G., 1980. Creation: Facts of Life, Creation-Life Publishers, San Diego.
20. Sleisenger. M.H. and Fordtran. J.S.. 1983. Gastrointestinal Disease. Saunders, third
edition, p.1268f.
21. Way, L.W., 1985. Current Surgical Diagnosis and Treatment, Lange. seventh edition.
22. England. M.A.. 1983. A Colour Atlas of Life Before Birth. Wolfe Med.
23. Chadwick. V.S. and Phillips. S., 1982. Small Intestine B.I.M.R. Gastroenterology 2.
Butterworth.
24. Alexander-Williams. I. and Binder. H.I., 1983. Large Intestine B.I.M.R.
Gastroenterology 3. Butterworth.
25. Doe. W., 1986. Immunology of the gastrointestinal tract. Medicine International.
2:1044f.
26. Perey. D. Y., Cooper. M.D. and Good. R.A.. 1968. The mammalian homologue of the
avian Bursa of Fabricius. Surgery, 64:614f.
27. Sussdorf. D.M. and Draper. L.R.. 1956. Antibodies in rabbits after irradiation; shielding
the appendix. J. of Infect. Dis., 99:129f.
28. Archer. O.K.. Sutherland. D.R. and Good. R.A.. 1963. The appendix in rabbits after
neonatal thymectomy. Nature. 200:337f.
29. Wangensteen. O.H. and Dennis. C.. 1939. Experimental proof of the obstructive origin of
appendicitis in man. Ann. Sorg., 110:629.

The Appendix—An Addition on the Appendix

The Latin word ‘addendum’ means an addition.

The Latin word ‘appendix, appendicis f.’ means an appendage -an addition at the end (of a book
for example), being an addition almost as an afterthought and not regarded as of great value to
the overall theme of the topic at hand. Thus whereas the choice of the adjective ‘vermiform’,
meaning worm-like, is accurately descriptive of the organ, the choice of the noun ‘appendix’
from the beginning of the organ’s nomenclature, gave it little chance of ever being considered
important.

In an excellent review article on ‘A History of Appendicitis’, in a presidential address to the 94th

meeting of the Southern Surgical Association, G. Rainey Williams, of the University of
Oklahoma Department of Surgery, pointed out that the reason the appendix is not mentioned in
very early anatomical studies is probably because the studies were done on animals not
possessing an appendix.’ Perusing the above and other excellent review articles on the history of
the appendix (Kelly and Hurdon,2 Shepherd,3 Seal4 and Maingot5) allows one to outline the
highlights of such a history:

1492 Leonardo da Vinci clearly depicted the organ in his anatomical drawings.
1521 Berengario DaCarpi first described the organ.
1530 Vido Vidius first named the worm-like organ as the vermiform appendix.
1543 Andreas Vesalius had it well illustrated in ‘De Humani Corporis Fabrica.’
Lorenz Heister gave the first good description of a case of acute appendicitis—a post
1711
mortem on an executed criminal.
Claudius Amyand performed the first recorded successful appendicectomy -the appendix,
1735 perforated by a pin, and surrounding omentum were removed through a scrotal wound
while dealing with a faecal fistula in a chronic hernia in an 11-year-old boy.
1767 John Hunter described a gangrenous appendix at post mortem.
1812 John Parkinson first described a faecolith in a perforated appendix at post mortem.
Francois Melier suggested the possibility of appendicectomy as an operation. Dupuytren
1827
opposed this view.
Bright and Addison published a medical textbook clearly outlining the symptomatology of
1839
acute appendicitis. Hodgkin agreed.
onwards—anaesthesia took off, perityphlitis abscesses drained —Hancock (1848), Willard
1850s
Parker (1867) and others (1870s)
1867 Joseph Lister gave his first paper on ‘Antisepsis’.
Lawson Tait operated with the express intent of performing appendicectomy having made
1880
a pre-operative diagnosis of disease of the organ.
1883 Abraham Groves of Ontario did likewise.
Mikulicz in Krakow recommended and performed surgery for appendicitis. Kronlein in
1884
Germany did likewise.
Charter Symonds, an Englishman, performed the first interval operation for appendicitis
1885
but did not remove the appendix.
Hall of New York in May performed appendicectomy but had not commenced the
1886
operation with such an intent.
Sir Frederick Treves of London unkinked an appendix in February of that year. Morton,
seven years after Tait in England and four years after Groves in Canada, in April of that
year performed the first deliberated appendicectomy for appendicitis in the United States.
1887
Treves recommended interval appendicectomy in September of that year. Sands in
December of that year removed an appendix, thus following what he had been preaching
for some time.
onwards for a decade brought improvement of technique -Treves, Senn, McBurney, Weir,
1888
Worcester, Fowler, Deaver, Marcy and Richardson.
1886 When —June 18, 1886, at the first meeting of the Association of American Physicians.
 Where—in Washington DC.
With the likes of Sternberg, Welch and Osler.
What—the first good description of perityphlitis and iliac passion was given.
By—Reginald Heber Fitz who was Shattuck Professor of Pathological Anatomy at
Harvard University.

R.H. Fitz read a paper entitled ‘Perforating Inflammation on the Vermiform Appendix
with Special Reference to its Early Diagnosis and Treatment’. He had been a pupil of
Virchow, and being a pathologist gave a detailed description of the pathology of the
condition. He used the term ‘acute appendicitis’ which mixes a Latin root ‘appendix,
appendicis f.’ and the Greek suffix ‘-itis’ implying inflammation and recommended early
surgery removal as treatment. He is also noted for a very good paper in 1889 on
‘Pancreatitis’.
June -McArthur was to speak on a muscle- splitting incision but the meeting went over
time and he did not present his paper.
1894
July -McBurney outlined the grid-iron incision and named his ‘point’.
Oschner and Sherren suggested a conservative regime to prevent infection spreading
1902
making subsequent surgery safer.
Murphy reported 2.000 appendicectomies between 1880 and 1903 mostly being what we
1904
call interval appendicectomies and named his triad (pain, vomiting and R.I.F. tenderness).
1905 Rockey described a transverse skin incision which Elliot had done in 1896.
1906 Davis, Harrington, Weir and Fowler all wrote on appendicectomy and incisions.

Among famous American surgeons of the time, Ephraim McDowell died of the disease, as did
Fowler, whereas Wangensteen survived. Walter Reid died of the disease. Harvey Gushing, the
father of modern neurosurgery, survived and Halsted was his surgeon.

Sir Frederick Treves was ‘The Elephant Man’s surgeon.

In 1902 he operated on Edward VII for an acute appendicitis with abscess the very day before
the King (as successor to his mother Queen Victoria, who died in 1901) was to have his
coronation. The coronation, of course, had to be postponed.

Treves performed the first unkinking of the appendix operation (1887) and in England and
Europe was known as a proponent for interval appendicectomy (also 1887). He described the
bloodless fold as part of the mesentery of the appendix, wrote on the positions or the appendix
around the caecal apex according to a clock race, and also wrote on the types or caecum to which
the appendix was attached. His own daughter died of acute appendicitis.

References
1. Williams. G.R., 1983. A history or appendicitis. Ann. Surg., 197:495f.
2. Kelly. H.A. and Hurdon. E., 1905. The Vermiform Appendix and Its Diseases. W.B.
Saunders, Philadelphia.
3. Shepherd. J.A., 1960. Surgery of the Acute Abdomen. E. & S. Livingston Ltd. p.401f.
4. Seal. A., 1981. Appendicitis: a historical review. Canadian J. of Surg., 24(4):427f.
5. Maingol. R., 1974. Abdominal Operations. Applelon-Century- Crofts, 6th edition.
Vol.2., p.1370 f.
The vestigiality of the human vermiform
appendix
A modern reappraisal
Copyright © 2003-2007 by Douglas Theobald, Ph.D.
[Last Update: April 19, 2007]

"The vermiform appendage—in which some recent medical writers have vainly endeavoured to
find a utility—is the shrunken remainder of a large and normal intestine of a remote ancestor.
This interpretation of it would stand even if it were found to have a certain use in the human
body. Vestigial organs are sometimes pressed into a secondary use when their original function
has been lost."

Joseph McCabe
The Story of Evolution (1912), p. 264
"Its major importance would appear to be financial support of the surgical profession."

Alfred Sherwood Romer and Thomas S. Parsons

The Vertebrate Body (1986), p. 389.

Other Links:
"Your appendix: It's there for a reason", by Ken Ham and Carl Wieland
An overstated view from the most influential creationist organization on the function
and purpose of the human appendix.
"The Human Vermiform Appendix – a General Surgeon's Reflections", by J. Warwick Glover,
M.D.
An anti-evolutionist and special-creationist doctor speaks on the possible functions of
the appendix.

Outline
• Introduction
• The vermiform appendix: background information
• The caecum
• The caecal apex and the appendix are homologous
• Intermediates between the caecum and the appendix
• Possible functions of the appendix
• The appendix is a suboptimal design
• Evolutionary misconceptions in the medical literature
 • How to disprove that the appendix is a vestige
• Conclusion
• Acknowledgements
• References

Introduction

Many biological structures can be considered vestiges given our current evolutionary knowledge
of comparative anatomy and phylogenetics. In evolutionary discussions the human vermiform
appendix is one of the most commonly cited vestigial structures, and one of the most disputed.
Evolutionary vestiges are, technically, any diminished structure that previously had a greater
physiological significance in an ancestor than at present. Independently of evolutionary theory, a
vestige can also be defined typologically as a reduced and rudimentary structure compared to the
same homologous structure in other organisms, as one that lacks the complex functions usually
found for that structure in other organisms (see, e.g. Geoffroy 1798).

Classic examples of vestiges are the wings of the ostrich and the eyes of blind cavefish. These
vestigial structures may have functions of some sort. Nevertheless, what matters is that
rudimentary ostrich wings are useless as normal flying wings, and that rudimentary cavefish eyes
are useless as normal sighted eyes. Vestiges can be functional, and speculative arguments against
vestiges based upon their possible functions completely miss the point.

For more discussion of the vestigial concept, extensive modern and historical references
concerning its definition (especially the allowance for functionality), see the Citing Scadding
(1981) and Misunderstanding Vestigiality and 29+ Evidences for Macroevolution: Anatomical
vestiges FAQs.

The following discussion makes four main points:

1. The human appendix may have bona fide functions, but this is currently controversial,
undemonstrated in humans, and irrelevant as to whether the appendix is a true vestige or
not.
2. The appendix is a prime example of dysteleology (i.e. suboptimal structural design), a
prediction of genetically gradual evolution.
3. The appendix is a rudimentary tip of the caecum and is useless as a normal, cellulose-
digesting caecum.
4. Thus, the appendix is vestigial by both the evolutionary and non-evolutionary,
typological definitions of vestigiality.

The vermiform appendix: background info

Figure 1: The human vermiform appendix (image reproduced
with modifications from Gray 1918)

In humans, the vermiform appendix is a small, finger-sized structure, found at the end of our
small caecum and located near the beginning of the large intestine (Fawcett and Raviola 1994, p.
636; Oxford Companion to the Body 2001, pp. 42-43; Williams and Myers 1994). The adjective
"vermiform" literally means "worm-like" and reflects the narrow, elongated shape of this
intestinal appendage. The appendix is typically between two and eight inches long, but its length
can vary from less than an inch (when present) to over a foot. The appendix is longest in
childhood and gradually shrinks throughout adult life. The wall of the appendix is composed of
all layers typical of the intestine, but it is thickened and contains a concentration of lymphoid
tissue. Similar to the tonsils, the lymphatic tissue in the appendix is typically in a constant state
of chronic inflammation, and it is generally difficult to tell the difference between pathological
disease and the "normal" condition (Fawcett and Raviola 1994, p. 636). The internal diameter of
the appendix, when open, has been compared to the size of a matchstick. The small opening to
the appendix eventually closes in most people by middle age. A vermiform appendix is not
unique to humans. It is found in all the hominoid apes, including humans, chimpanzees, gorillas,
orangutans, and gibbons, and it exists to varying degrees in several species of New World and
Old World monkeys (Fisher 2000; Hill 1974; Scott 1980).

The caecum: a specialized herbivorous organ

Our appendix is a developmental derivative and evolutionary vestige of the end of the much
larger herbivorous caecum found in our primate ancestors (Condon and Telford 1991; Williams
and Myers 1994, p. 9). The word "caecum" actually means "blind" in Latin, reflecting the fact
that the bottom of the caecum is a blind pouch (a dead-end or cul-de-sac).

In most vertebrates, the caecum is a large, complex gastrointestinal organ, enriched in mucosal
lymphatic tissue (Berry 1900), and specialized for digestion of plants (see Figure 2; Kardong
2002, pp. 510-515). The caecum varies in size among species, but in general the size of the
caecum is proportional to the amount of plant matter in a given organism's diet. It is largest in
obligate herbivores, animals whose diets consist entirely of plant matter. In many herbivorous
mammals the caecum is as large as the rest of the intestines, and it may even be coiled and longer
than the length of the entire organism (as in the koala). In herbivorous mammals, the caecum is
essential for digestion of cellulose, a common plant molecule. The caecum houses specialized,
symbiotic bacteria that secrete cellulase, an enzyme that digests cellulose. Otherwise cellulose is
impossible for mammals to digest.

The structure of the caecum is specialized to increase the efficiency of cellulose fermentation. As
a "side branch" from the gut it is able to house a large, dense, and permanent colony of
specialized bacteria. Being a dead-end sac at the beginning of the large intestine, it allows more
time for digesting food to reside in the gut and ferment more completely, before passing through
the large intestine where the resulting nutrients are absorbed. However, even though humans are
herbivorous, the small human caecum does not house significant quantities of cellulase-excreting
bacteria, and we cannot digest more than but a few grams of cellulose per day (Slavin, Brower,
and Marlett 1980).

Figure 2: Gastrointestinal tracts of various mammals. For each species, the stomach is shown at top, the small
intestine at left, the caecum and associated appendix (if present) in magenta, and the large intestine at bottom right. Scale
differs between species. Reproduced with modifications from Kardong 2002, p. 511. Copyright © 2002 McGraw-Hill.
The human appendix is homologous to the end of the mammalian caecum

In vertebrate comparative anatomy, it has long been known that the human appendix and the end
of the mammalian caecum are structurally homologous (Berry 1900; Fisher 2000; Hill 1974;
Hyman 1979, p. 412; Kardong 2002, pp. 513-515; Kluge 1977, p. 1977; Neal and Rand 1936, p.
315; Romer and Parsons 1986, p. 389; Royster 1927, p. 27; Smith 1960, p. 305; Weichert 1967,
p. 189; Wiedersheim 1886, p. 236; Wolff 1991, p. 384). Of course, the end of the caecum and the
appendix can be homologous and have different functions. Being the termination of the caecum,
the human vermiform appendix is also a "blind pouch," and another name for the appendix is in
fact the "true caecal apex" (Berry 1900). Within the gastrointestinal tract of many vertebrates,
mammals, and primates in particular, the termination of the caecum and the vermiform appendix
share the same relative position (Figure 2), both have a similar structure and form, both are blind
sacs enriched with lymphatic tissue (Berry 1900), both have a common developmental origin
(Condon and Telford 1991; Williams and Myers 1994, p. 9), and, as discussed below, in the
primates both are connected by an extensive series of intermediates. These observations firmly
establish these structures as homologous by standard systematic criteria (Kitching et al. 1998, pp.
26-27; Remane 1952; Schuh 2000, pp. 63-64; Rieppel 1988, p. 202), a conclusion confirmed by
cladistic systematic analysis (Goodman et al. 1998; Shoshani 1996).

A few other mammals appear to have a structure similar to the hominoid vermiform appendix,
including the wombat, South American opossum (both marsupials), some rodents, and the rabbit.
However, extensive comparative analysis has shown that the caecal appendixes of humans and
these other mammals were derived from the caecum independently; these structures are not
homologous as appendixes (Shoshani and McKenna 1998). The relationship between these other
caecal structures and the hominoid vermiform appendix is similar to the homology of bat and
bird wings. The wings of bats and birds are homologous as modified forelimbs, yet they are not
homologous as wings. Likewise, the appendixes of rabbits and humans are homologous as
modified caeca, yet they are not homologous as appendixes. If the rabbit and human appendix
have similar functions (which has never been experimentally demonstrated), they are the result
of independent convergence of function and form (Shoshani and McKenna 1998). The many
significant morphological, histological, and cellular differences between the rabbit and human
appendixes (discussed below) all are consistent with a superficial convergent relationship.

Structural intermediates of the appendix and caecum in primate phylogeny

The primate family tree provides a rather complete set of intermediates between the states "large
caecum/appendix absent" to "small caecum/appendix present". Many primates have both a
caecum and an appendix, or a structure intermediate between the two. The anatomical definition
of a vermiform appendix is a narrowed, thickened, lymphoid-rich caecal apex (Fisher 2000 and
references therein). As already mentioned, the hominoid apes all bear a vermiform appendix, but
many non-anthropoid primates also have structures that fit the above definition to varying
degrees. In fact, recent reevaluation of the anatomy of the primate caecum and appendix has
highlighted the difficulties in determining exactly where the caecum ends and the appendix
begins in different species (Fisher 2000). This complication arises from the continuous, variable,
and overlapping nature of caecal and appendicular tissues, both histologically and anatomically.
For example, in most primates the caecal apex is rich in lymphoid tissue and is thickened, but
whether it is narrowed into a conical or "worm-like" structure is variable (Fisher 2000).

From systematic analysis of comparative anatomy, it is known that in primates a large caecum
with a small or absent appendix is the ancestral, primitive state (Goodman et al. 1998; Shoshani
1996). In general, the length of the caecum, relative to that of the colon, decreases as one
traverses the primate phylogenetic tree from monkeys to humans. Concurrently, the size of the
appendix increases. The appendix is mostly absent in prosimians and New World monkeys, yet
they have a large caecum. In Old World monkeys the appendix is more recognizable, and it is
well-developed in the anthropoid apes, which lack the large cellulose-fermenting caecum found
in their ancestors and other primates (Fisher 2000; Goodman et al. 1998; Hill 1974; Shoshani
1996; Scott 1980).

Possible function of the appendix

"The appendix n, of the colon n m, is a part of the caecum and is

capable of contracting and dilating so that excessive wind does not
rupture the caecum."

Leonardo da Vinci
FB 14v (1504-1506).
from O'Mally and Saunders 1952, Leonardo da Vinci on the Earliest known drawing of
human body, p. 185. the appendix,
by Leonardo da Vinci.

Throughout medical history many possible functions for the appendix have been offered,
examined, and refuted, including exocrine, endocrine, and neuromuscular functions (Williams
and Myers 1994, pp. 28-29). Today, a growing consensus of medical specialists holds that the
most likely candidate for the function of the human appendix is as a part of the gastrointestinal
immune system. Several reasonable arguments exist for suspecting that the appendix may have a
function in immunity. Like the rest of the caecum in humans and other primates, the appendix is
highly vascular, is lymphoid-rich, and produces immune system cells normally involved with the
gut-associated lymphoid tissue (GALT) (Fisher 2000; Nagler-Anderson 2001; Neiburger et al.
1976; Somekh et al. 2000; Spencer et al. 1985). Animal models, such as the rabbit and mouse,
indicate that the appendix is involved in mammalian mucosal immune function, particularly the
B and T lymphocyte immune response (Craig and Cebra 1975). Animal studies provide limited
evidence that the appendix may function in proper development of the immune system in young
juveniles (Dasso and Howell 1997; Dasso et al. 2000; Pospisil and Mage 1998).

However, contrary to what one is apt to read in anti-evolutionary literature, there is currently no
evidence demonstrating that the appendix, as a separate organ, has a specific immune function in
humans (Judge and Lichtenstein 2001; Dasso et al. 2000; Williams and Myers 1994, pp. 5, 26-
29). To date, all experimental studies of the function of an appendix (other than routine human
appendectomies) have been exclusively in rabbits and, to a lesser extent, rodents. Currently it is
unclear whether the lymphoid tissue in the human appendix performs any specialized function
apart from the much larger amount of lymphatic tissue already distributed throughout the gut.
Most importantly with regard to vestigiality, there is no evidence from any mammal suggesting
that the hominoid vermiform appendix performs functions above and beyond those of the
lymphoid-rich caeca of other primates and mammals that lack distinct appendixes.

As mentioned above, important differences exist in nearly all respects between the human and
rabbit appendixes (Dasso et al. 2000; Williams and Myers 1994, p. 57). The rabbit appendix, for
instance, is very difficult to identify as separate from the rest of its voluminous caecum (see
Figure 2). Unlike the human appendix, the rabbit's appendix is extremely large, relative to the
colon, and is the seat of extensive cellulose degradation due to a specialized microflora. The
large rabbit appendix houses half of its GALT lymphoid tissue, whereas the contribution of the
human appendix to GALT is significantly less (Dasso et al. 2000). In humans the vast majority
of GALT tissue is found in hundreds of Peyer's patches coating the small intestine and in nearly
10,000 similar patches found in the large intestine. Additionally, there are important differences
in lymphoid follicular structure, in T-cell distribution, and in immunoglobulin density (Dasso et
al. 2000). Furthermore, from systematic analysis we know that the rabbit, rodent, and human
appendixes are convergent as outgrowths and constrictions of the caecum (Shoshani and
McKenna 1998). It is thus very questionable to conclude from these animal studies that the
human appendix has the same function as the other non-primate appendixes.

Of course, over a century of medical evidence has firmly shown that the removal of the human
appendix after infancy has no obvious ill effects (apart from surgical complications, Williams
and Myers 1994). Earlier reports of an association between appendectomy and certain types of
cancer were artifactual (Andersen and Isager 1978; Gledovic and Radovanovic 1991;
Mellemkjaer et al. 1998). In fact, congenital absence of the appendix also appears to have no
discernable effect. From investigative laparoscopies for suspected appendicitis, many people
have been found who completely lack an appendix from birth, apparently without any
physiological detriment (Anyanwu 1994; Chevre et al. 2000; Collins 1955; Hei 2003; Host et al.
1972; Iuchtman 1993; Kalyshev et al. 1995; Manoil 1957; Pester 1965; Piquet et al. 1986;
Ponomarenko and Novikova 1978; Rolff et al. 1992; Saave 1955; Shperber 1983; Tilson and
Touloukian 1972; Williams and Myers 1994, p. 22).

In sum, an enormous amount of medical research has centered on the human appendix, but to
date the specific function of the appendix, if any, is still unclear and controversial in human
physiology (Williams and Myers 1994, pp. 5, 26-29).

The appendix is suboptimally designed

The human appendix is notorious for the life-threatening complications it can cause. Deadly
infection of the appendix at a young age is common, and the lifetime risk of acute appendicitis is
7% (Addiss et al. 1990; Hardin 1999; Korner et al. 1997; Pieper and Kager 1982). The most
common age for acute appendicitis is in prepubescent children, between 8 and 13 years of age.
Before modern 20th-century surgical techniques were available, a case of acute appendicitis was
usually fatal. Even today, appendicitis fatalities are significant (Blomqvist et al. 2001; Luckmann
1989).
The small entrance to this dead-end pocket makes the appendix difficult to clean out and prone to
physical blockage, which ultimately is the cause of appendicitis (Liu and McFadden 1997). This
peculiar structural layout is quite beneficial for a larger cellulose-fermenting caecum, but it is
unclear why gut lymphoid tissue would need to be housed in a remote, dead-end tube with
negligible surface area. In fact, 60% of appendicitis cases are due to lymphoid hyperplasia
leading to occlusion of the interior of the appendix, indicating that the appendix is unusually
prone to abnormal proliferation of its lymphoid tissue (Liu and McFadden 1997). Such an
occurrence would be much less problematic if the interior of the appendix were not so small,
confined, and inaccessible from the rest of the gut. In many other primates and mammals, the
GALT lymphoid tissue appears to function without difficulty in a much more open, bulbous
caecum with ample surface area.

Furthermore, there is mounting evidence that removing the appendix helps prevent ulcerative
colitis, a nasty inflammatory disease of the colon (Andersson et al. 2001; Buergel et al. 2002;
Judge and Lichtenstein 2001; Koutroubakis and Vlachonikolis 2000; Koutroubakis et al. 2002;
Naganuma 2001; Rutgeerts 1994). This evidence suggests that the appendix is actually
maladaptive, and that the lymphoid tissue contained in the appendix is prone to chronic
pathological inflammatory states. If the appendix does have an important function that we have
yet to find, it is a leading candidate for the worst designed organ in the human body. How nice if
the appendix would just degenerate away after it is no longer needed, so it could never get
infected and kill us needlessly. Any biological structure that supposedly ensures our livelihood
by its functions, yet paradoxically and unnecessarily kills a large fraction of its bearers
prematurely, is poorly designed indeed.

Why do some medical sources question the vestigiality of the appendix?

The reasons for this are multiple, but they largely stem from the simple fact that most physicians
are not trained in evolutionary biology. The erroneous "completely nonfunctional" definition of a
vestige is primarily found in medical papers, textbooks, and dictionaries (e.g. Williams and
Myers 1994, p. ix). Using this incorrect and nonevolutionary definition, it is logical to conclude
that a structure is not vestigial if its function is discovered. For instance, based upon this
incorrect definition, Williams and Myers 1994 incorrectly argue that an evolutionary vestige
cannot be both a complex and a "regressive" structure (p. 27). Similarly, a modern version of
Gray's Anatomy confusingly implies that the appendix cannot be both vestigial and specialized
(Williams and Warwick 1980). However, vestiges are very often complex or specialized
structures, in fact overly complex for their functions, and prime examples are the wing of the
ostrich and the eyes of blind cavefish. A vestige can be a complex structure, in an absolute sense,
while simultaneously being rudimentary or degenerate relative to the same homologous structure
in other organisms.

Perhaps most important is the fact that a vestige can be identified only via comparative analysis.
Physicians are experts on human anatomy and physiology, but rarely do discussions in medical
publications consider phylogenetic and comparative issues. Medical articles that attempt to
consider phylogenetics often provide a gross misconception of evolutionary fundamentals. For
instance, the most thorough and in depth source on the physiology of the human appendix,
Williams and Myers 1994, refers to how the appendix changes as "the primate scale is ascended"
and to the "evolutionary scale" with humans at its end (pp. 26-27). These are long-refuted
orthogenetic concepts which have been contradicted by basic evolutionary theory since Darwin.
Scott 1980 similarly argues against vestigiality based upon orthogenetic concepts and a belief in
evolutionary "progress." Fisher 2000 (p. 229) and Scott 1980 both incorrectly imply that a
vestige cannot be a derived character, a curious assessment since a vestige must be a
phylogenetically derived character by definition.

How would we know if the appendix were not vestigial?

Whether the appendix has a function of some sort or not has no direct bearing on whether it is a
bona fide vestige. However, at least three possible observations would help negate the
conclusion that the human appendix is vestigial, using either the evolutionary or the typological
definitions of vestigiality:

• (1) if the human appendix were actually as large and developed as, say, the caecum of a
prosimian or New World monkey;
• (2) if the human appendix contributed significantly to cellulose fermentation and
contained a large amount of cellulose-digesting bacteria;
• (3) if we could demonstrate via phylogenetic or systematic methods that the apex of the
cellulose-fermenting caecum in other primates and the vermiform appendix were not
structurally homologous as side branches from the intestine.

An additional possible observation would contradict the conclusion of vestigiality by the

evolutionary definition:

• (4) if phylogenetic methods indicated that no predicted ancestors of humans ever had a
large, cellulose-fermenting caecum (i.e., that a large, cellulose-digesting caecum is
actually a derived primate character, not a primitive one).

All four of these potential observations are demonstrably false. Additionally, each is based upon
positive scientific evidence: (1) we can measure and quantitate the size of the appendix; (2) we
can measure and quantitate the amount of cellulose digestion occurring in the appendix; (3) we
can observe and compare the relative positions, underlying structures, forms, and development of
the organs in the gastrointestinal tracts of various organisms; and (4) we can determine primitive
and derived characters by independent phylogenetic analysis. Therefore, the conclusion of
vestigiality is susceptible and open to scientific testing against empirical observation. As such the
concept of vestigiality is not an "argument from ignorance." It is clearly scientific in nature,
based completely upon positive evidence.

Conclusion: The vermiform appendix is vestigial

Currently, arguments against the vestigiality of the human vermiform appendix have been based
upon misunderstandings of what constitutes a vestige and of how vestiges are identified.

From an evolutionary perspective, the human appendix is a derivative of the end of the
phylogenetically primitive herbivorous caecum found in our primate ancestors (Goodman et al.
1998; Shoshani 1996). The human appendix has lost a major and previously essential function,
namely cellulose digestion. Though during primate evolution it has decreased in size to a mere
rudiment, the appendix retains a structure that was originally specifically adapted for housing
bacteria and extending the time course of digestion. For these reasons the human vermiform
appendix is vestigial, regardless of whether or not the human appendix functions in the
development of the immune system.

From a nonevolutionary, typological perspective, the human appendix is homologous to the end
of the physiologically important, large, cellulose-fermenting caeca of other mammals. Even
though humans eat cellulose, the contribution to cellulose digestion by both the human caecum
and its associated appendix is negligible. Regardless of whether one accepts evolutionary theory
or not, the human appendix is a rudiment of the caecum that is useless as a normal mammalian,
cellulose-digesting caecum. Thus, by all accounts the vermiform appendix remains a valid and
classic example of a human vestige.
Vermiform Appendix
Author: Steven L Lee, MD, Chief, Pediatric Surgery, Department of Surgery, Kaiser-
Permanente, Los Angeles Medical Center
Coauthor(s): Shant Shekherdimian, MD, Consulting Surgeon, Department of Surgery, Kaiser
Foundation Hospital; Jeffrey J DuBois, MD, Consulting Staff, Division of Pediatric Surgery,
Kaiser Permanente, North Sacramento Medical Center
Contributor Information and Disclosures

Updated: Nov 24, 2008

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Introduction
In 1886, Reginald H. Fitz, a Harvard pathologist, first described the clinical condition of acute
appendicitis.1 He correctly pointed out the importance of its early diagnosis and timely treatment,
based on his analysis of 257 cases of perforating inflammation of the appendix and 209 cases of
typhlitis or perityphlitis.2

A few years later, Charles McBurney described the clinical findings prior to rupture and
advocated early surgical intervention. Despite aggressive intervention, mortality and morbidity
rates remained high through the rest of the 19th century and the first half of the 20th century. The
mortality rate associated with appendicitis declined with the introduction of antibiotics and with
the development of anesthesia and better perioperative care.
Currently, the diagnosis of acute appendicitis remains a challenge. Only slightly more than half
of patients present with classic signs and symptoms of acute appendicitis. Atypical presentations
often lead to a delay in diagnosis, perforation, prolonged hospitalization, and increased
morbidity.3 Thus, all clinicians must be knowledgeable about diagnosing and managing this
disease process.

For excellent patient education resources, visit eMedicine's Esophagus, Stomach, and Intestine
Center. Also, see eMedicine's patient education articles, Appendicitis and Abdominal Pain in
Adults.

History of the Procedure

The appendix was probably first noted as early as the Egyptian civilization (3000 BC). During
the mummification process, abdominal parts were removed and placed in Coptic jars with
inscriptions describing the contents. When these jars were uncovered, inscriptions referring to
the "worm of the intestine" were discovered.4

Aristotle and Galen did not identify the appendix because they both dissected lower
animals, which do not have appendices. Celsus, however, probably discovered the
appendix because he was allowed to dissect criminals executed by Caesar.4
Leonardo da Vinci first depicted the appendix in anatomic drawings in 1492.5 In
1521, Jacopo Beregari da Capri, a professor of anatomy in Bologna, identified the
appendix as an anatomic structure. In the 1500s, Vesalius (1543) and Pare (1582)
referred to the appendix as the caecum. Laurentine compared the appendix to a
twisted worm in 1600, and Phillipe Verheyen coined the term appendix vermiformis
in 1710.4

Problem

Acute appendicitis remains one of the most common surgical diseases encountered by
physicians. When appendicitis manifests in its classic form, it is easily diagnosed and treated.
Unfortunately, these classic symptoms occur in just over half of patients with acute appendicitis;
therefore, an accurate and timely diagnosis of atypical appendicitis remains clinically
challenging and one of the most commonly missed problems in the emergency department.
Furthermore, the consequence of missing appendicitis, thus leading to perforation, significantly
increases morbidity and prolongs hospitalization.6

Frequency

In Western countries, approximately 7% of individuals develop appendicitis at some time during

their lives. Approximately 200,000 appendectomies are performed annually in the United States.1

The peak incidence of acute appendicitis has gradually declined to about half of its peak
incidence in the early 20th century, with the current annual incidence of 1 per 1000 population in
the United States and 86 cases for every 100,000 persons worldwide.7,8
Acute appendicitis is less common in Africa and in parts of Asia because of the high-residue
diets of the inhabitants.

Etiology

Appendicitis results from obstruction of the lumen of the appendix. Obstruction may be from
lymphoid hyperplasia (60%), fecalith or fecal stasis (35%), foreign body (4%), and tumors
(1%).9

Pathophysiology

The basic pathophysiology of appendicitis is obstruction of the lumen of the appendix followed
by infection. In 60% of patients, obstruction is caused by hyperplasia of the submucosal follicles.
This form of obstruction is mostly observed in children and is known as catarrhal appendicitis. A
fecalith or fecal stasis causes luminal obstruction 35% of the time and is usually observed in
adults. Obstruction may also be caused by foreign bodies (4%) and tumors (1%).

Following obstruction, an increase in mucous production occurs, and this leads to increased
pressure. With increased pressure and stasis from obstruction, bacterial overgrowth ensues. The
mucus then turns into pus that causes a further increase in luminal pressure. This leads to
distention of the appendix and visceral pain, which is typically located in the epigastric or
periumbilical region.

As the luminal pressure continues to increase, lymphatic obstruction occurs, leading to an

edematous appendix. This stage is known as acute or focal appendicitis. The overlying parietal
peritoneum becomes irritated, and the pain now localizes to the right lower quadrant (RLQ). This
series of events results in the classic migrating abdominal pain described in patients with
appendicitis.

Further increase in pressure leads to venous obstruction, causing edema and ischemia of the
appendix. At this stage, bacterial invasion of the wall of the appendix occurs and is known as
acute suppurative appendicitis. Finally, with continued pressure increases, venous thrombosis
and arterial compromise occur, leading to gangrene and perforation.9 If the body successfully
walls off the perforation, the pain may actually improve. However, symptoms do not completely
resolve. Patients may still have underlying right lower quadrant pain, decreased appetite, change
in bowel habits (eg, diarrhea, constipation), or intermittent low-grade fever. If the perforation is
not successfully walled off, then diffuse peritonitis will develop.

Presentation

The classic presentation of a patient with appendicitis includes a history of initial periumbilical
or epigastric abdominal pain migrating to the RLQ. The pain is gradual in onset and
progressively worsens. Anorexia, nausea, and vomiting are typically associated with the disease.
In early appendicitis, the patient is initially afebrile or has a low-grade fever. Higher fevers are
associated with a perforated appendix.3
On physical examination, the patient is usually lying still, as movement worsens the pain.
Having the patient cough elicits localized pain in the RLQ. Local tenderness to palpation is
usually observed. Percussion tenderness is also noted in this area. Tenderness on the right side
during rectal examination may occur, whereas pelvic and testicular examination findings are
normal. Other signs (eg, Rovsing, psoas, obturator) are unreliable and typically occur late in the
disease process.3

Unfortunately, only 55% of patients with appendicitis present with classic history and physical
findings. This is because the early signs and symptoms are primarily dependent upon the location
of the tip of the appendix, which is highly variable.9

Indications
Indications for surgical consultation

A surgeon should evaluate any patient with classic migrating abdominal pain and RLQ
tenderness. Because only a little more than half of patients with appendicitis present with a
classic history and physical findings, acute appendicitis should be on the list of possible
diagnoses for any patient with abdominal pain. Thus, a surgeon should also evaluate patients
with focal RLQ tenderness or progressively worsening abdominal pain.

To minimize the time between presentation and appendectomy, obtain surgical consultation prior
to performing additional diagnostic studies, such as CT scan, ultrasound, and technetium (Tc)-
labeled WBC scan.3

Indications for operation

Any patient with suspected appendicitis who has (1) persistent pain and becomes febrile, (2) an
increasing WBC count, or (3) worsening clinical examination findings should undergo
appendectomy or at least diagnostic laparoscopy. In patients with an atypical presentation, the
most important determination for appendectomy is serial physical examinations. The WBC count
often does not increase after the patient is admitted and hydrated; therefore, any patient sent
home from the emergency department should undergo a follow-up evaluation the next day.3

Relevant Anatomy
Embryologically, the appendix is a continuation of the cecum and is first delineated during the
fifth month of gestation. The appendix does not elongate as rapidly as the rest of the colon, thus
forming a wormlike structure.1

The appendix averages 10 cm in length but can range from 2-20 cm. The wall of the appendix
consists of 2 layers of muscle, an inner circular and outer longitudinal. The longitudinal layer is a
continuation of the taeniae coli. The appendix is lined by colonic epithelium.1
Few submucosal lymphoid follicles are noted at birth. These follicles enlarge, peak from 12-20
years, and then decrease. This correlates with the incidence of appendicitis.

Blood supply to the appendix is mainly from the appendicular artery, a branch of the ileocolic
artery. This artery courses through the mesoappendix posterior to the terminal ileum. An
accessory appendicular artery can branch from the posterior cecal artery. This artery can lead to
significant intraoperative and postoperative hemorrhage and should be searched for carefully and
ligated once the main appendicular artery is controlled.9

The base of the appendix is fairly constant and is located at the posteromedial wall of the cecum
about 2.5 cm below the ileocecal valve. This is also where the taeniae converge.9

The base is at a constant location, whereas the position of the tip of the appendix varies. In 65%
of patients, the tip is located in a retrocecal position; in 30%, it is located at the brim or in the
true pelvis; and, in 5%, it is extraperitoneal, situated behind the cecum, ascending colon, or distal
ileum. The location of the tip of the appendix determines early signs and symptoms.

Contraindications
No contraindications to performing an appendectomy in patients with suspected appendicitis
exist; however, patients with a well-developed abscess (detected on CT scan) following
perforated appendicitis may be initially treated with percutaneous drainage and intravenous
antibiotics.

Once bowel function resumes, the patient may be discharged on oral antibiotics (total IV plus PO
antibiotics for 7-10 d) with consideration for interval appendectomy in 6 weeks.10
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Wikipedia

Vermiform appendix
Infobox Anatomy
Name = Vermiform Appendix
Latin = appendix vermiformis
GraySubject = 249
GrayPage = 1178

Caption = Arteries of cecum and vermiform appendix. (Appendix visible at lower right, labeled as "vermiform
process").

Caption2 = Normal location of the appendix relative to other organs of the digestive system (frontal view).
Precursor = Midgut
System = Digestive
Artery = appendicular artery
Vein = appendicular vein
MeshName = Appendix
MeshNumber = A03.556.124.526.209.290
DorlandsPre = a_54
DorlandsSuf = 12147735
In human anatomy, the appendix (or vermiform appendix; also cecal (or caecal) appendix;
also vermix) is a blind ended tube connected to the cecum (or caecum), from which it develops
embryologically. The cecum is a pouch-like structure of the colon. The appendix is near the
junction of the small intestine and the large intestine.

The term "vermiform" comes from Latin and means "worm-like in appearance".

ize and location

The appendix averages 10 cm in length, but can range from 2 to 20 cm. The diameter of the
appendix is usually between 7 and 8 mm. The longest appendix ever removed measured 26 cm in
Zagreb, Croatia.
[http://www.guinnessworldrecords.com/records/human_body/body_parts/largest_appendix_removed.aspx Guinness
world record for longest appendix removed.] ] The appendix is located in the lower right quadrant of the
abdomen, or more specifically, the right iliac fossa.Paterson-Brown S. The acute abdomen and
intestinal obstruction. Chapter 15 in Garden O.J., Bradbury A.W., Forsythe J.L.R., Parks R.W.
(2007) Principles and Practise of Surgery, Fifth Edition, Churchill Livingstone Elsevier.] Its
position within the abdomen corresponds to a point on the surface known as McBurney's point
(see below). While the base of the appendix is at a fairly constant location, 2 cm below the
ileocaecal valve , the location of the tip of the appendix can vary from being retrocaecal (74% )
to being in the pelvis to being extraperitoneal. In rare individuals with situs inversus, the
appendix may be located in the lower left side.

Function

Given the appendix's propensity to cause death via infection, and the general good health of
people who have had their appendix removed, the purpose of the appendix has mystified
scientists for some time. There have been cases of people who have been found, usually on
laparoscopy or laparotomy, to have a congenital absence of an appendix. There have been no
reports of impaired immune or gastrointestinal function in these people.

Vestigiality

The most common explanation is that the appendix is a vestigial structure which now has no
purpose. In " [http://onlinebooks.library.upenn.edu/webbin/gutbook/lookup?num=1043 The Story of Evolution]
", Joseph McCabe argued thus:

The vermiform appendage—in which some recent medical writers have vainly endeavoured to
find a utility—is the shrunken remainder of a large and normal intestine of a remote ancestor.
This interpretation of it would stand even if it were found to have a certain use in the human
body. Vestigial organs are sometimes pressed into a secondary use when their original function
has been lost.

One potential ancestral purpose put forth by DarwinDarwin, Charles (1871) "Jim's Jesus". "The
Descent of Man, and Selection in Relation to Sex". John Murray: London.] was that the appendix
was used for digesting leaves as primates. Over time, we have eaten fewer vegetables and have
evolved, over thousands of years, for this organ to be smaller to make room for our stomach. It
may be a vestigial organ of ancient man that has degraded down to nearly nothing over the
course of evolution. Evidence can be seen in herbivorous animals such as the Koala. The cecum
of the koala is attached to the juncture of the small and large intestines and is very long, enabling
it to host bacteria specific for cellulose breakdown. Early man’s ancestor must have also relied
upon this system and lived on a diet rich in foliage. As man began to eat more easily digested
foods, they became less reliant on cellulose-rich plants for energy. The cecum became less
necessary for digestion and mutations that previously had been deleterious were no longer
selected against. These alleles became more frequent and the cecum continued to shrink. After
thousands of years, the once-necessary cecum has degraded to what we see today; the appendix.

Evolutionary theorists have suggested that natural selection selects for larger appendices because
smaller and thinner appendices would be more susceptible to inflammation and disease [cite news|
title=The old curiosity shop|work=New Scientist|date=2008-05-17|
url=http://www.newscientist.com/channel/being-human/mg19826562.100-vestigial-organs-remnants-of-
evolution.html] .

Immune Use

Loren G. Martin, a professor of physiology at Oklahoma State University, argues that the
appendix has a function in fetuses and adults. [cite news|url=http://www.sciam.com/article.cfm?id=what-
is-the-function-of-t|title=What is the function of the human appendix? Did it once have a purpose that has since
been lost?|work=Scientific American|date=1999-10-21|accessdate=2008-07-01] Endocrine cells have been
found in the appendix of 11 week old fetuses that contribute to "biological control (homeostatic)
mechanisms." In adults, Martin argues that the appendix acts as a lymphatic organ. The appendix
is experimentally verified as being rich in infection-fighting lymphoid cells, suggesting that it
might play a role in the immune system. Zahid [Zahid, A. (2004) "The vermiform appendix: not
a useless organ." J Coll Physicians Surg Pak. 14:256-258.
[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=15228837&dopt=Abstract
PubMed] ] suggests that it plays a role in both manufacturing hormones in fetal development as
well as functioning to 'train' the immune system, exposing the body to antigens in order that it
can produce antibodies. He notes that doctors in the last decade have stopped removing the
appendix during other surgical procedures as a routine precaution, because it can be successfully
transplanted into the urinary tract to rebuild a sphincter muscle and reconstruct a functional
bladder.

Latest Interpretation: Maintaining gut flora

Although it was long accepted that the immune tissue, called gut associated lymphoid tissue,
surrounding the appendix and elsewhere in the gut carries out a number of important functions,
explanations were lacking for the distinctive shape of the appendix and its apparent lack of
importance as judged by an absence of side-effects following appendectomy. Robbins Pathologic
Basis of Disease, 4th edition, 1989, pages 902-903 ] William Parker, Randy Bollinger, and
colleagues at Duke University proposed that the appendix serves as a haven for useful bacteria
when illness flushes those bacteria from the rest of the intestines. [cite news|
url=http://www.msnbc.msn.com/id/21153898/|title=Scientists may have found appendix’s purpose: Seemingly
useless organ may produce, protect good germs for your gut|date=2007-10-05|accessdate=2008-07-01|
work=MSNBC] Bollinger, R.R., Barbas, A.S., Bush, E.L., Lin, S.S. & Parker. W. (2007) Biofilms
in the large bowel suggest an apparent function of the human vermiform appendix. J. Theoretical
Biology. doi:10.1016/j.jtbi.2007.08.032.] This proposal is based on a new understanding of how
the immune system supports the growth of beneficial intestinal bacteria [ Sonnenburg JL, LT
Angenent, JI Gordon. Getting a grip on things: how do communities of bacterial symbionts
become established in our intestine? Nature Immunology. 2004;5:569-73 ] [ Everett ML, D
Palestrant, SE Miller, RR Bollinger, W Parker. Immune exclusion and immune inclusion: a new
model of host-bacterial interactions in the gut. Clinical and Applied Immunology Reviews.
2004;5:321-332. ] , in combination with many well-known features of the appendix, including its
architecture and its association with copious amounts of immune tissue. Such a function is
expected to be useful in a culture lacking modern sanitation and healthcare practice, where
diarrhea may be prevalent. Current epidemiological data [ Statistics on the cause of death in
developed countries collected by the World Health Organization in 2001 show that acute
diarrhea is not the fourth leading cause of disease-related death in developing countries (data
summarized by The Bill and Melinda Gates Foundation).Fact|date=December 2007 Two of the other
leading causes of death are expected to have exerted limited or no selection pressure on humans
in the distant past because one (HIV-AIDS) only very recently emerged and another (ischaemic
heart disease) primarily affects people in their post-reproductive years. Thus, acute diarrhea
may have been one of the primary disease-related selection pressures on the human population
in the past. (Lower respiratory tract infection (pneumonia) is the remaining of the top four
leading causes of disease-related death in third world countries.) ] show that diarrhea is one of
the leading causes of death in developing countries, indicating that a role of the appendix as an
aid in recovering beneficial bacteria following diarrhea may be extremely important in the
absence of modern health and sanitation practices.

Diseases

The most common diseases of the appendix (in humans) are appendicitis and carcinoid tumors.
Appendix cancer accounts for about 1 in 200 of all gastrointestinal malignancies. Adenomas also
(rarely) present.

Appendicitis (or epityphlitis) is a condition characterized by inflammation of the appendix. Pain

often begins in the center of the abdomen, corresponding to the appendix's development as part
of the embryonic midgut. This pain is typically a dull, poorly localised, visceral pain.

As the inflammation progresses, the pain begins to localise more clearly to the right lower
quadrant, as the peritoneum becomes inflamed. This peritoneal inflammation, or peritonitis,
results in rebound tenderness (pain upon "removal" of pressure rather than "application" of
pressure). In particular, it presents at McBurney's point, 1/3 of the way along a line drawn from
the Anterior Superior Iliac Spine to the Umbilicus. Typically, point (skin) pain is not present
until the parietal peritoneum is inflamed as well. Fever and an immune system response are also
characteristic of appendicitis.

Many cases of appendicitis require removal of the inflamed appendix, either by laparotomy or
laparoscopy. Untreated, the appendix may rupture, leading to peritonitis, followed by shock, and,
if still untreated, death.

The surgical removal of the vermiform appendix is called an appendicectomy (or

appendectomy). This procedure is normally performed as an emergency procedure, when the
patient is suffering from acute appendicitis. In the absence of surgical facilities, intravenous
antibiotics are used to delay or avoid the onset of sepsis; it is now recognized that many cases
will resolve when treated non-operatively. In some cases the appendicitis resolves completely;
more often, an inflammatory mass forms around the appendix. This is a relative contraindication
to surgery.