How would you like to be the young surgeon in 1902 who was asked to see Prince Edward, who was to be crowned King of England in two days? His Mother, Queen Victoria, had reigned so long Edward had become the playboy prince. Now he was obese, old, flatulent and a terrible operative risk. Young Dr. Treves diagnosed a ruptured appendix and recommended surgery, much to the consternation of other doctors.
While Treves operated, officials were preparing for the king's funeral. But Treves got lucky. His decision proved prudent. He simply drained an abscess and left the appendix alone. No doubt Treves also lifted more than one prayer to the Almighty. Luckily, Edward survived and was later crowned King Edward VII of England. Treves was knighted for his efforts.
A report from the Canadian Medical Protective Association shows it's not only kings who develop a ruptured appendix. Some form an abscess and kill patients. Others do not.
This year about 250,000 appendectomies will be done in North America. Fortunately, it's rare today to die from uncomplicated appendicitis. But when trouble strikes, the cause is usually a delay in diagnosis and treatment.
A typical attack of appendicitis starts with abdominal pain. But contrary to what most people think, it doesn't begin in the right side. Rather, it starts in the upper part of the abdomen. Sometimes it's only a nagging discomfort. But at other times it can be associated with severe pain along with nausea and vomiting.
After several hours the pain finally gravitates to the lower right side. This soreness is apt to be increased by coughing or any other jolt. Normally, there is also a slight elevation of temperature. The great problem is this textbook description of appendicitis doesn't always happen.
The Canadian Medical Protective Association report outlines common problems that can trigger complications. For example, one patient complained of abdominal pain lasting two days, along with nausea and vomiting. But the doctor believed the abdominal discomfort was related to sore muscles due to strain of vomiting. She was discharged with a diagnosis of gastroenteritis. But then in this case, and frequently in others, a big mistake occurred. The patient was not provided with adequate information of what to do if symptoms failed to subside.
Several days later the patient's condition deteriorated and she was seen in the emergency department. This time the diagnosis was a ruptured appendix with abscess. But now the patient also required removal of part of the large and small bowel. What could have been a simple appendectomy had turned into a major procedure.
In another case, a grossly overweight patient with vague abdominal complaints was sent home and advised to return if fever, vomiting or the pain became worse. A few days later a CT scan diagnosed appendicitis and surgery was performed with a happy outcome. But obesity always makes the diagnosis more difficult and complications more likely.
Today, more cases of appendicitis are being diagnosed by either CT scans or ultrasound. In addition, some appendectomies are being performed by laparoscopy, resulting in a shortened post-operative recovery.
Can the King Edward disease be prevented? Appendicitis is virtually unknown in Kenya, Uganda, Egypt and India where people eat a high-fibre diet. And during the second World War, when the Swiss were forced to consume less refined sugar and more fibre, their rate of appendicitis dropped.
It's interesting how the surgical treatment of appendectomy has changed over the years. The great French surgeon, Dupuytren, ridiculed the notion that it was impossible for such a small organ to produce such disastrous results.
Others disagreed with him. In 1855, one surgeon, Henry Sands of New York, merely stitched up the perforated hole in an appendix. He then returned the appendix to the abdomen and the patient survived. More due to the grace of the Almighty than sound surgical judgment, it seems.
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