Appendectomies became a routine surgical procedure in the late 1880s and 1890s, after a pathologist named Reginald Fitz formally identified the appendix as the culprit behind a deadly abdominal condition that had been killing patients for centuries. Before Fitz’s landmark 1886 paper, surgeons occasionally removed an inflamed appendix by accident or desperation, but the operation had no standardized name, no agreed-upon technique, and no clear rationale. Within about a decade of his work, appendectomy went from a rare improvisation to one of the most frequently performed emergency surgeries in the Western world, a status it still holds today.
Centuries of Confusion Before the Breakthrough
The appendix caused trouble long before anyone understood what it was doing. The earliest known successful appendectomy was performed in 1735 by Claudius Amyand, a surgeon at St. George’s Hospital in London, who removed a perforated appendix from an 11-year-old boy during a hernia repair.1PubMed. History of surgical treatment of appendicitis A few years earlier, in 1731, a surgeon named Cookesley had inadvertently removed an appendix during a groin hernia operation, and in 1757 Mestivier became the first to drain an abscess in the lower-right abdomen caused by appendicitis.2PubMed Central. Three Centuries of Appendicectomy These were isolated events separated by decades. Nobody connected them into a coherent picture of a single disease.
The problem was partly one of language. For most of the 18th and 19th centuries, doctors attributed the severe right-sided abdominal pain we now call appendicitis to inflammation of the cecum, the pouch where the small and large intestines meet. They used terms like “typhlitis” and “perityphlitis,” which pointed to the wrong structure and led to the wrong treatment. Patients were managed with rest, ice packs, and opium while doctors debated whether the inflammation was muscular, mucosal, or something else entirely. Many died of perforation and peritonitis.
Fitz, McBurney, and the 1880s Turning Point
The transformation began in 1886, when Reginald Fitz, a Harvard pathologist, presented a paper to the Association of American Physicians arguing that the small worm-shaped appendix, not the cecum, was the source of the deadly inflammation. He coined the term “appendicitis,” replacing the outdated labels that had misdirected treatment for generations.3PubMed Central. Acute appendicitis and its treatment: a historical overview Fitz also made a bold clinical recommendation: early surgical removal of the appendix before it ruptured.
Surgeons responded quickly. In 1884, Rudolf Krönlein had performed an appendectomy for acute appendicitis, but the patient died. The first successful appendectomy for acute appendicitis with patient survival came in 1887, credited to Thomas Morton in Philadelphia.2PubMed Central. Three Centuries of Appendicectomy In Manhattan, Charles McBurney refined the diagnosis and the operation itself. He described the clinical signs of appendicitis, including the now-famous “McBurney’s point” of maximum tenderness, and developed the muscle-splitting incision technique that bears his name and remained the standard surgical approach for about a century.4JAMA. CHARLES McBURNEY (1845-1913)— POINT, SIGN, AND INCISION By the early 1900s, the operation was being taught in medical schools across the United States and Europe, and the era of treating appendicitis conservatively was ending.
Why Appendicitis Rates Exploded in the 20th Century
Appendectomies didn’t just become common because surgeons learned how to do them. The disease itself became dramatically more frequent during the first half of the 20th century. A systematic review of population-based studies found that appendicitis incidence peaked in North America in the 1940s, with rates in New York State reaching about 383 cases per 100,000 people per year. In Europe, the peak came later and hit even higher: Germany recorded roughly 601 per 100,000 in the 1960s. New Zealand peaked in the 1940s at about 331 per 100,000.5Annals of Surgery. The Global Incidence of Appendicitis: A Systematic Review of Population-based Studies These are striking numbers. At those rates, appendicitis was one of the most common reasons a person would end up in an operating room.
The pattern also showed a clear relationship with industrialization. Regions that modernized later saw their peaks later. Asia’s highest rates came in the 2000s, with South Korea reaching about 206 per 100,000. The Middle East, South America, and Africa followed similar delayed trajectories.5Annals of Surgery. The Global Incidence of Appendicitis: A Systematic Review of Population-based Studies This worldwide pattern, where appendicitis rises as a country industrializes and then gradually declines, has been one of the more puzzling epidemiological trends of the past century.
What Was Driving the Epidemic
Two main theories have competed to explain why appendicitis tracked so closely with modernization: diet and hygiene.
The dietary fiber hypothesis owes much to Denis Burkitt, a surgeon who spent decades working in Africa and noticed that diseases common in wealthy countries, including appendicitis, were rare in populations eating high-fiber diets. Burkitt built on earlier work by Peter Cleave, Hugh Trowell, and others to propose that over-processing of natural foods, and the resulting drop in fiber intake, played a central role in conditions ranging from appendicitis and diverticulosis to heart disease and colon cancer.6PubMed. Denis Burkitt and the origins of the dietary fibre hypothesis The idea was that low-fiber diets slow bowel transit, allow harder stool to accumulate, and create conditions where the narrow opening of the appendix is more likely to become blocked. A small study comparing fiber intake in appendicitis patients with matched controls found that the appendicitis group consumed significantly less fiber per day, around 17 grams versus 21 grams.7JAMA Surgery. Acute Appendicitis and Dietary Fiber
A more recent reassessment of Burkitt’s hypothesis notes that he attributed a cluster of “high-income lifestyle-associated diseases” to the low fiber consumption typical of industrialized countries, following the logic that diseases appearing together in the same populations probably share a common cause.8PubMed Central. The association between dietary fibre deficiency and high-income lifestyle-associated diseases: Burkitt’s hypothesis revisited The fiber story is plausible but far from settled, partly because the decline in appendicitis rates in Western countries began before fiber intake rose again.
The hygiene hypothesis offers a competing explanation. A study of British children found a relationship between appendicitis and markers of improved sanitation, supporting the idea that growing up in an increasingly clean environment altered immune development in ways that made the appendix more prone to inflammation.9PubMed. Acute appendicitis and bathrooms in three samples of British children Under this theory, children in less sanitary settings are exposed to a wider range of microbes early in life, and this shapes the immune tissue concentrated in the appendix in a protective way. As indoor plumbing, water treatment, and overall sanitation improved, the immune environment of the gut may have shifted in ways that increased vulnerability to appendicitis. Neither hypothesis alone fully accounts for the pattern, and the truth probably involves elements of both along with other factors still being studied.
The Negative Appendectomy Problem
For most of the 20th century, surgeons operated on the principle that it was better to remove a healthy appendix than to miss a diseased one. The reasoning was straightforward: a ruptured appendix can be fatal, so erring on the side of surgery was considered acceptable. Historically, a negative appendectomy rate of 10 to 20 percent was seen as a tolerable cost of catching perforated cases early.10The American Journal of Surgery. High negative appendectomy rates are no longer acceptable That meant roughly one in every six or seven patients who went under the knife turned out not to have appendicitis at all.
CT imaging changed the math considerably. As hospitals began using CT scans for patients with suspected appendicitis, diagnostic accuracy improved. One study documented the shift in real time: CT usage rose from about 12 percent to 34 percent of cases over a relatively short period, and the rate of unnecessary appendectomies dropped from 14 percent to 7 percent.11PubMed. Appendicitis: selective use of abdominal CT reduces negative appendectomy rate Better imaging didn’t just spare patients from unnecessary surgery; it also allowed doctors to distinguish between complicated cases that needed the operating room urgently and uncomplicated cases that might have other options.
The Laparoscopic Revolution
For nearly a century after McBurney standardized his open incision in the 1890s, the basic technique of appendectomy changed remarkably little. Then, in 1980, a German gynecologist named Kurt Semm performed the first fully laparoscopic appendectomy, using a camera and small instruments inserted through tiny incisions rather than a single large one.12PubMed Central. Kurt Semm and the fight against skepticism: endoscopic hemostasis, laparoscopic appendectomy, and Semm’s impact on the “laparoscopic revolution” The surgical establishment was not enthusiastic. Semm faced fierce resistance from colleagues who considered the technique dangerous and unnecessary. The head of the German Surgical Society reportedly demanded that Semm be suspended from medical practice.
But the advantages of laparoscopy were hard to argue with: smaller scars, less post-operative pain, shorter hospital stays, and faster recovery. By the 1990s, as laparoscopic equipment improved and training spread, the technique began to take over. Today, laparoscopic appendectomy is the standard approach in most of the developed world, and the open McBurney incision is reserved mainly for complicated cases or settings where laparoscopic equipment is unavailable. The shift from open to laparoscopic surgery represents one of the biggest changes in how appendectomies are actually performed since the operation was invented.
Can You Skip the Surgery Entirely
Perhaps the most significant recent challenge to the appendectomy’s dominance is the growing evidence that many cases of uncomplicated appendicitis can be treated with antibiotics alone. For over a century, the assumption was that an inflamed appendix had to come out, period. That assumption is now being questioned seriously.
A large randomized trial published in the New England Journal of Medicine compared antibiotics with appendectomy for uncomplicated appendicitis and found that antibiotics were not inferior to surgery based on quality-of-life measures at 30 days.13PubMed. A Randomized Trial Comparing Antibiotics with Appendectomy for Appendicitis A meta-analysis of the broader literature reached a similar conclusion: an increasing body of evidence supports antibiotic treatment as a viable alternative to surgery for patients whose appendicitis is uncomplicated, meaning the appendix hasn’t perforated or developed an abscess.14JAMA. Antibiotic Therapy vs Appendectomy for Treatment of Uncomplicated Acute Appendicitis
The catch is that a significant proportion of antibiotic-treated patients eventually come back with another episode and end up having surgery anyway. This has kept the debate lively. For patients who want to avoid surgery, or who have medical conditions that make anesthesia risky, antibiotics offer a real option. But appendectomy remains the definitive treatment, and most surgeons still consider it the default for anyone who is a reasonable surgical candidate.
Surgery in Extreme Isolation
The appendectomy’s status as an essential emergency procedure is illustrated by one of medicine’s more extraordinary stories. In 1961, Leonid Rogozov, a Soviet surgeon stationed at a remote Antarctic research base, developed acute appendicitis. With no other doctor within reach and no possibility of evacuation, he performed an appendectomy on himself, using local anesthesia and a mirror, with assistance from a meteorologist and a mechanic who held instruments and retractors.15PubMed. Auto-appendectomy in the Antarctic: case report He survived and recovered. The case became famous not just for its drama but for what it revealed about the stakes of appendicitis in settings where surgery is not readily available. It also prompted military and polar organizations to reconsider whether prophylactic appendectomies should be performed on personnel heading to long-duration isolated postings, a debate that persisted for decades.
The Appendix Isn’t What We Thought It Was
For most of the time appendectomies have been performed, doctors assumed the appendix was a useless evolutionary leftover. Darwin himself suggested it was a vestige of a larger cecum that had shrunk as human diets changed. This “vestigial organ” framing made appendectomy seem like an uncomplicated win: remove a ticking time bomb that serves no purpose.
That view has been challenged substantially. An evolutionary analysis found that the cecal appendix has evolved independently at least 32 times across mammalian species but has been lost fewer than seven times, a pattern that strongly suggests it provides some survival advantage rather than being a mere remnant.16Comptes Rendus Palevol. Multiple independent appearances of the cecal appendix in mammalian evolution and an investigation of related ecological and anatomical factors Further research has pointed to the appendix as a reservoir for beneficial gut bacteria. After a severe bout of diarrheal illness that flushes the intestinal tract, the appendix may serve as a kind of biological backup, re-seeding the gut with the healthy microbial communities it needs to function.17PubMed. A review of the function and evolution of the cecal appendix The appendix is also densely packed with immune tissue and appears to play a role in immune surveillance and development, particularly early in life.
This reassessment doesn’t mean appendectomies are unwise when the appendix is actively inflamed and threatening to burst. An inflamed appendix remains a genuine emergency. But the new understanding has dampened enthusiasm for so-called incidental appendectomies, where surgeons removed a healthy appendix during an unrelated abdominal procedure simply because it was convenient. It has also added nuance to the antibiotics-versus-surgery debate: if the appendix has a real function, there is added reason to preserve it when safely possible.
Where Appendectomy Rates Are Headed
The global picture is surprisingly uneven. In countries that industrialized earliest, appendicitis rates peaked decades ago and have been declining since, though the operation remains extremely common. In parts of Asia, the Middle East, South America, and Africa, incidence rates were still climbing into the 2000s.5Annals of Surgery. The Global Incidence of Appendicitis: A Systematic Review of Population-based Studies As surgical infrastructure expands in lower-income countries, appendectomy volumes in those regions are likely to rise even as they stabilize or fall in wealthier ones.
Meanwhile, the procedure itself keeps evolving. Single-incision laparoscopic techniques, natural orifice surgery, and robotic-assisted approaches are all being explored, though conventional laparoscopy remains dominant. The antibiotic alternative is gaining ground slowly, and some hospitals now offer it as a first-line option for carefully selected patients with imaging-confirmed uncomplicated disease. The appendectomy is unlikely to disappear. It has been one of the defining operations of modern surgery for well over a century. But the days of “when in doubt, cut it out” are gradually giving way to a more individualized approach that weighs the risks, the imaging findings, the patient’s preferences, and a growing respect for what the appendix actually does.