The following blog post was written by Museum of Health Care Curator Maxime Chouinard.
The appendix represents quite a mystery. For many years it was believed to be a vestige of our distant ancestors; the trace of a cecum, a part of many animals large intestine.[1] This theory was put forward by Charles Darwin, but was mostly refuted in 2013.[2]
Another theory claims that the appendix acts as a safe haven for gut bacteria in case of disease; the bacteria could regenerate from this point into the rest of the intestine. [3]
Whatever its true function, the appendix can cause severe problems when it becomes infected. In such cases the most common response is to remove the appendix, a procedure called appendectomy. While today it is considered a relatively common procedure, more than a century ago it would have been quite a feat.
In this article we will present a story of a spectacular and early appendectomy. This is a story that was passed down through the family of Mr. Stephen Shimeal, whom came to the museum this summer to share it with us.
The Smell of Carbolic Acid
In 1896, the young Violet Minetta Simpson, then 6 years old, was suffering from an acute appendicitis. Her family was at the time living in Grand Valley, Ontario, and decided to consult the local physician. Considering her condition to be fatal, the physician told them that the best course of action would be to attempt an appendectomy; a procedure that was first named and executed only a decade before.
A significant problem remained: the physician had never done nor observed any abdominal surgery before. However, he did own a copy of an American medical journal (possibly the Boston Medical and Surgical Journal) which described, in detail, the process of an appendectomy…
Realizing that they had nothing to lose, the Simpsons agreed to the procedure. They took a photo of their daughter, knowing that it might be their last chance to do so. Taking a photograph at the time was quite expensive, and many families only managed to take pictures post mortem. They were instructed to give her no food after dinner, and only clean water until midnight.
They then proceeded to clean their kitchen, which was to be transformed into an operating theatre. The physician was a strong believer in Listerism, and so every bed sheet in the house was boiled, soaked in carbolic acid, and then used to line the room with and create makeshift surgical gowns.
The table was thoroughly scrubbed with boiling water and doused in carbolic acid as well. So much of the substance was used that the entire house reeked of tar for months. Even though the physician was not fond of anaesthesia, Violet’s father was put in charge of administering the ether, while the mother was holding up the journal and turning the pages so that the physician could follow the instructions.
The procedure went well and Violet stayed in bed for several weeks. She eventually recuperated, in full health, and went on to live 80 more years.
From da Vinci to Edward VII: a medical history of the appendix
The appendix itself was first illustrated by Leonardo da Vinci in 1492, and was described by da Capri and Vesalius later on. However, until the late 19th century, appendectomy was an extremely rare procedure.
The first recorded instance of such a surgery was in 1735 London, where the French Huguenot surgeon Claudius Amyand undertook the removal of a young boy’s appendix. Amyand had previously served in the British army, and was named surgeon-in-ordinary for George II.
The patient was Hanvil Anderson, 11 years old, and suffered from a hernia. Upon opening the abdomen, the surgeon saw that the appendix was badly inflamed and even perforated. Fearing for the boy’s life, Amyand decided to do something that had never been done before; remove the appendix. The consequences were uncertain, would the patient survive and would he be able to live a normal life afterwards? The surgery was conducted at St. George’s Hospital and was a success. Amyand later presented his procedure to the Royal Society, of which he was a fellow. Upon examining the appendix he found a pin, which had been swallowed by the boy and thus caused the appendicitis.
“This operation proved the most complicated and perplexing I ever met; with many unsuspected Oddities and Events concurring to make it as intricate as it proved laborious and difficult….’Tis easy to conceive that this Operation was as painful to the Patient as laborious to me…..It lasted nearly half an Hour – and the Patient bore it with great Courage. He was composed by half an Ounce of Diacodium (a syrup made of poppies) and Emollient Embrocations (a balm to soften the skin).”[4]
Curiously, Amyand’s work subsequently fell in obscurity, and appendectomy was not to be tried again until the 1880s. By then the advent of anaesthesia and antisepsis gave rise to more complex surgeries. The first to try the procedure again was Robert Lawson Tait in 1880’s Edinburgh. Tait was treating a seventeen year old girl suffering from acute pain and showing a characteristic swelling in the right lower abdomen. Tait decided to operate and found the appendix to be inflamed and even gangrenous. He decided to remove it and close off the opening with fine silk. [5]
Even though this procedure proved successful, most surgeons recommended it only when an abscess was formed. Such a cautious approach unfortunately caused 35 percent of patients to die from acute peritonitis, as Reginal Hebert Fitz demonstrated. Fitz, a pathology professor at Harvard, was the first to coin the term appendicitis, and suggested the appendix should be removed at the earliest stage. [6]
This approach was imitated by most American surgeons, while Europeans maintained the conservative approach until 1902, when King Edward VII was operated at an early stage of swelling. His fast recovery convinced many surgeons of the importance of acting quickly.
Today appendectomy has become a common procedure. The introduction of antibiotics and laparoscopy made the recovery much quicker for many patients. Even today new innovations are being made, namely with single-incision laparoscopic surgery. Thanks to these discoveries, appendicitis is now easily treatable. New research shows that appendectomy might be superfluous in many cases where antibiotics can do the same job just as effectively.[7]
Endnotes
[1] Darwin, Charles. The descent of man and selection in relation to sex. John Murray: London, 1871.
[2] Smith H. F., Parker W., Kotzé, S. H., Laurin, M. Multiple independent appearances of the cecal appendix in mammalian evolution and an investigation of related ecological and anatomical factors. Comptes rendus Palevol, 2013.
[3] Bollinger, R.R.; Barbas, A.S.; Bush, E.L.; Lin, S.S.; Parker, W. Biofilms in the large bowel suggest an apparent function of the human vermiform appendix. Journal of Theoretical Biology 249, 2013, pp. 826–831.
[4] Martyn, John. The Philosophical Transactions (From the Year 1731, to the Year 1744); Vol. IX. W. Innis, 1747, p.153-156.
[5] De Moulin, D. A history of surgery: with emphasis on the Netherlands. Springer Science & Business Media, 2012.
[6] Fitz R. Perforating inflammation of the vermiform appendix, with special reference to its early diagnosis and treatment. Trans Assoc Am Physicians 1, 1886, pp.107-44.
[7] Salminen P, Paajanen H, Rautio T, et al. Antibiotic Therapy vs Appendectomy for Treatment of Uncomplicated Acute Appendicitis: The APPAC Randomized Clinical Trial. JAMA. 313, 2015, pp.2340-2348.