A Case of Appendicitis

London was abuzz with excitement and expectation in late June, 1902. The coronation of the new king, Edward VII was to take place on the 26th in Westminster Abbey where monarchs had been crowned for a millennium. Vast swathes of the crowned heads of Europe were to attend; not for nothing was Edward known as the ‘uncle of Europe’. Edward had reinvented the role of the monarchy after the dreary years of Victoria; he reimagined all the pomp and ceremonial associated with the coronation; and every ceremonial we see today is very much his legacy. All sorts of souvenirs of the day were available; flats overlooking the processional route were being rented out for extortionate sums, and all traders were expecting a bumper time.

Meanwhile, in a room not far from the Abbey, a conclave of physicians and surgeons was discussing the illness of a patient with him. The patient was middle aged, distinctly obese, a heavy smoker and a known glutton and heavy drinker. Despite these considerable handicaps, the advisability of an operation was being taken seriously—but not by the patient.

His illness had begun 10 days previously. He had had abdominal pain which seemed to settle low down on the right side of the belly. He felt rather better soon enough, well enough to go for a drive in his carriage. However, although a mass had later developed in the belly, his medical advisers were against an operation, and the mass seemed to resolve, and his condition similarly improved. But, after a particularly gargantuan banquet on the evening of the 23rd—eight large courses, each with their own wine—his condition markedly worsened, leading to the consultation on the morning of the 24th June.

Despite their entreaties, the fat patient refused to change his mind; tempers began to rise. The king—for it was he—felt he knew his responsibilities, his duty. “I must keep faith with my people,” he said, “I must go to the Abbey”. Frederick Treeves, well known for his association with the ‘Elephant Man’, was one of the surgeons in attendance. Treeves was not a man to suffer fools or monarchs gladly; he was not a man to be cowed into silence by the majesty of the vast imperial presence. He replied,

Then, Sire, you will go in your coffin.

The king acquiesced. A room was made ready in Buckingham Palace for the procedure, an operating table was sourced, and later that morning the king was anaesthetised and prepared. Treeves, assisted by Lord Lister, a septuagenarian who had suffered a stroke, drained an appendix abscess; the king’s appendix was not removed. During the procedure the king had a respiratory arrest; his airway became blocked and he stopped breathing. The anaesthetist, Sir Frederick Hewitt, grabbing the king’s beard and pulling mightily upwards on it, reopened the airway. (The operating table, after much use in the RVH, is now in the Department of Surgery at QUB.)

The following day, the king was able to sit in bed and smoke a cigar; he made an uncomplicated recovery. The coronation, inevitably postponed, was held on 9th August. It was a much more muted affair; the king was well enough to be able to support the totally decrepit Archbishop of Canterbury during the ceremony.

***

The king’s illness and operation was widely publicised; appendicectomy subsequently became very popular, almost fashionable, even if the king’s—or what was left of it—remained inside him.

Though certainly known for centuries, appendicitis was first scientifically described in the latter part of the 19th century. Operations at this time were rare; Treeves was the first surgeon in England to perform an appendicectomy. Whether the publicity given to the king’s illness meant that appendicitis was more often correctly diagnosed, or whether there was a real increase in incidence is unclear.

The primary reason for appendicectomy is to prevent peritonitis, the infection and inflammation of the lining of the abdomen; untreated, this is fatal. The appendix is a blind ended, hollow, worm-like appendage at the start of the large bowel, and lies in the lower right side of the belly. The natural history of appendicitis isn’t clearly known, as operation is advised when the condition is diagnosed, but probably follows these courses. Inflammation begins inside the appendix, and gradually spreads through the walls of the organ. Central, crampy abdominal pain moves to the right iliac fossa as the inflammation involves the whole organ and the local peritoneum in the area. There is usually a low-grade rise in temperature; it is at this stage that the organ is removed. This inflammation may resolve over a period of a few days, or persist and worsen so that the appendix ruptures, either directly into the peritoneal cavity, or locally forming an abscess. The abscess may resolve or settle, or it may rupture into the abdomen. In retrospect, it seems probable that the king suffered an episode of appendicitis 10 days before his operation, which initially improved, only then to worsen as a localised inflammatory mass. This too settled, until the banquet on the evening of the 23rd when it was reinvigorated, at which stage it was clearly an abscess.

Although operation is the gold standard method of treatment, a report from US navy submarines included a description of 100 sailors who had symptoms of appendicitis and who were treated with antibiotics; all survived without complications. Clearly, some of the seamen may not have had appendicitis. Whether antibiotic treatment is superior to operation in more normal practice in a properly equipped hospital remains unclear (here); overall, opinion still favours operation over antibiotics, in part because there cannot be recurrent episodes. Such conservative management will still require observation in a hospital for a few days; the overall cost savings are likely to be imaginary. And, of course, the diagnosis of appendicitis may be wrong. The appendix can be removed at an open operation, or by keyhole (laparoscopic) surgery. Recovery after keyhole surgery is quicker, but specialised equipment is needed. Whether, after an appendix abscess has been drained, the appendix should be removed at a second operation is uncertain; some experts think that the inflammation has destroyed the appendix, others fear a further attack.

There’s a further very clear lesson from the king’s story; that no matter how elevated the person may be, no matter how deep the purse of a private patient may be, no matter if the patient is the humblest peasant in the land, they should all be treated equally on the merits of their illness. The patient should be able to make an informed judgement about the benefits and drawbacks of any operation. And if this demands the telling of brutal ’truth to power’, well, so be it.

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