Abstract
William Cookesley, a surgeon in Devon, England, successfully operated on a patient with an Amyand hernia in 1731, incidentally excising the appendix. His patient is the earliest documented to have survived appendicectomy. This was confirmed by a post mortem examination 31 years later. Part of the remaining bowel was preserved by William Hunter and this specimen remains in the Hunterian Museum in Glasgow.
The first successful appendicectomy is generally accepted to have been performed by Claudius Amyand, Surgeon to King George II, in 1735 at St George’s Hospital in London. An 11-year-old boy had presented with an indirect inguinal hernia associated with an enterocutaneous fistula opening in the groin. When Amyand operated on the boy’s hernia, a pin was found to have perforated the appendix, which was in the hernia sac in the scrotum. He removed the pin, and ligated and excised the appendix. The boy recovered. 1
Consequently, an inguinal hernia sac containing the appendix, whether inflamed or not, is now referred to as an Amyand Hernia. These constitute less than 1% of inguinal hernias. Almost all are right-sided. 2
Four years earlier in 1731, William Cookesley, a general practitioner surgeon in Crediton in Devon, England, had operated on a patient with an incarcerated scrotal hernia and excised the appendix along with other gangrenous bowel. The patient made a complete recovery. Cookesley’s case history was published in 1742. 3 That the appendix had been removed was confirmed at post mortem examination 31 years later.
The patient, Abraham Pike, was a 30-year-old chimney sweep.
He had had a reducible scrotal hernia for several years, which became incarcerated in September 1731. For about two weeks, he was in severe pain and constipated. Dr George Bent MD, a Crediton physician, was called to see him. He confirmed a large hernia with inflammation of the overlying skin, and told him to see a surgeon.
Local surgeon, William Cookesley, attended him the next morning, by which time the inflamed skin had broken down. He found a putrid discharge from the scrotum containing pus, faeces and gangrenous bowel. With his “scissars” he excised some necrotic bowel and about half of the right side of the scrotum. He noted that there was no bleeding. He applied dressings and gradually the wound healed although, as he predicted, faeces continued to discharge through the fistula. He prescribed clysters (enemas) and over the next month the fistula gradually closed.
In his article (Figure 1) written 11 years after the operation, Cookesley claimed that his patient was then cured of his hernia, had put on weight, was still working and was healthier than he had been for years. Cookesley believed that he had excised six inches of small bowel. Dr Bent corroborated the clinical details, although apparently remained sceptical that a length of small bowel had been removed.
First part of Cookesley’s 1742 report.
Abraham Pike died in Crediton on 3 January 1763, 31 years after his operation.
The following day, Dr Bent, who had been informed of Pike’s death, came from Exeter to Crediton bringing John Symons, an Exeter surgeon. At Bent’s request, Symons performed a post mortem examination to determine whether small bowel had been excised as Cookesley had claimed. He found that the caecum was adherent to the anterior abdominal wall. The ileum and colon appeared normal. The appendix and the lower part of the caecum were missing.
In 1746, Symons had been one of Dr William Hunter’s pupils in London. He then became his assistant before moving to Exeter. He sent Hunter the bowel which he had excised and, describing his findings in a letter, speculated that the appendix “is of no great use in the adult …”.
Hunter prepared and preserved this specimen, which is now kept in the Hunterian Museum in Glasgow (Figure 2). It is described as Lower end of the ileum and beginning of the colon, with a portion of the whole thickness of the abdominal parietes adhering to the latter, inflated and dried, from a patient who had recovered from a strangulated hernia 31 years before.
4
William Hunter's preparation of the excised bowel (1763). ©The Hunterian, University of Glasgow ref LAHM:121180.
An extract of Symons’s letter describing the post mortem findings was published in 1767.
5
It included an etching by Jan van Rymsdyk of the excised bowel (Figures 3 and 4).
Etching of Hunter's specimen by Jan van Rymsdyk (1767). Credit: Wellcome Library, London. Legend for Figure 3 above.
Little is known about William Cookesley. According to Symons’s 1763 letter, by that date Cookesley had been dead for many years.
Discussion
Amyand and Cookesley both operated on patients who had an inguinal hernia containing the appendix. In both cases, the presenting problem was associated with an inguinal hernia, and the appendicectomies were incidental. It seems likely that Cookesley, whose 1731 operation was performed four years earlier than Amyand’s, was the first surgeon to operate successfully on a patient with this condition, even though he was not aware of what part of the intestine he was removing. Perhaps Cookesley’s name, rather than Amyand’s, should be associated with the presence of the appendix in an inguinal hernia. Abraham Pike was probably the first person documented to have survived appendicectomy.