Subject: Re: Preventive surgery (was: Circumcision It aint so bad)

From: [email-masked]
Date: Tue, 19 Dec 95 13:45:37 PDT

In Article<[email-masked]>, <[email-masked]> write:
> In article <[email-masked]>,
> Carolyn Capps <[email-masked]> wrote:

> > The medical profession has never found any use for the appendix, ...
> 
> This is wrong.  We know the purpose of the appendix.  It is
> vestigal in humans, but in other species, it is a functioning
> part of the digestive system. 

Specifically, it is highly developed in grazing animals which digest 
cellulose, and seems to play a role in this process.  (Humans cannot digest 
cellulose - "fiber" - and the appendix in humans is tiny.)

> > but we all know of many cases of appendicitis which occur in adults 
> > to their great inconvenience and discomfort. It is arguable that 
> > it is actually negligent to submit a person to the possibility of
> > appendicitis when it could so easily be prevented by a little
> > judicious surgery in infancy. 
> 
> There are two problems with this.  First, abdominal surgery still
> carries significant risk.  Second, with current surgical
> techniques, it might be hard to cost justify.  If surgical
> techniques advance as many people expect over the next century,
> removing these problems, it might indeed become the case that
> appendectomies and similar preventive surgeries are routinely
> performed on infants and children.

Actually, routine removal of the healthy appendix in the course of other 
abdominal surgery - referred to as "incidental appendectomy" - was common in 
the middle of this century, up until the late 70s or early 80s.  The 
practice was justified on exactly the grounds Ms. Capps suggests - that it 
prevented later appendicitis.  However, it was criticized as adding 
unnecessary surgical risks, by prolonging the operation, creating a wound in 
the bowel with risk of infection or abdominal cavity contamination, and 
adding to the patient's surgical trauma.  It was also seen as a manipulative 
way for surgeons to pad their bills.  What finally put a stop to it, though, 
were several court cases in which surgeons were sued, not for malpractice, 
but for *assault* for exceeding the limits of the patient's consent to an 
operation; the surgeons lost when it could be shown that the procedure in 
question was not necessary to protecting the patient's life or was one the 
patient might have objected to.  Now, incidental appendectomy is unheard of. 
 There were concerns that these court cases would diminish surgeons' freedom 
of action in operations - which is exactly what they were intended to do and 
did.  Surgeons argued, though, that they needed to be free to take action to 
correct unforseen conditions found in the operation; today, surgical consent 
forms usually specify that the surgeon may remove cancers or correct other 
life-threatening conditions, but these are not seen as giving the surgeons 
an unrestrained hand.

As for operating prophylactically to remove the appendix in the absence of 
appendicitis, that also is unheard of, for the reasons Turpin notes - the 
cost and operative risk outweigh the expected good to be achieved.  However, 
I am not clear that any forseeable advance in operative technique is likely 
to shift this balance; unless some method of performing these operations is 
found which reduces both the likelihood of post-operative abdominal 
contamination *and* patient discomfort and recovery-period restrictions to 
an extremely small level, the operation will still be worse than the 
*expected* injury from appendicitis for the *average* patient.  That is, 
since most people never get appendicitis anyway, the operation will not 
really be preventing anything that would have been likely to occur for most 
people who get it prophylactically; thus, the operation does not merely have 
to be safer than the disease, or even safer than the same operation done 
under emergency conditions, but in fact so safe and comfortable that it 
would be reasonable to have it even in the face of a very small likelihood 
that it would turn out to have been useful.  Conceivably, some people might 
think that a good idea, but most wouldn't, and I doubt the medical 
profession would be likely to advise the operation routinely under any 
forseeable conditions.

As for the chance that other prophlactic operations will become routine as 
the result of advances in surgical technique, I consider that even less 
likely.  Most operations (aside from cosmetic ones) are performed to correct 
a mechanical problem in the body which has arisen from disease or injury - 
to correct a condition which didn't previously exist.  It is not *possible* 
to perform most operations until the patient has contracted the condition 
being relieved - you can't remove a tumor that hasn't grown yet.  
Prophylactic appendectomy is possible for three reasons: it addresses a 
problem which always arises, by definition, in a pre-defined organ; the 
operative procedure involves removal, rather than corrective manipulation, 
of the organ; and that organ is pretty much vestigial.  Few other operations 
have these characteristics; ones that do not cannot be performed 
prophylactically, since: you would not know where to perform it; it could 
not be performed until the condition to be corrected had already arisen; and 
removal of a non-vestigial organ is a drastic step only justified by serious 
disease.

ObAppendix: Some people have suggested that the appendix is not really 
vestigial in humans after all; there is little evidence as to what it does, 
but some cautious types and some "New-Age" mystical types just think that 
there must be a reason for it, since it's there.  If so, that would be even 
better reason not to whack it out indiscriminately, but there's little other 
than wishful thinking behind this position.

ObAppendectomy: Dian Fossey ("Gorillas in the Mist") wrote that she went to 
a prominent anthropologist for support in her plans to work with apes, when 
she was still in graduate school; he said he'd take her on his team if she'd 
have an appendectomy, because it would be dangerous to get appendicitis in 
the jungle away from a hospital.  So she went back to the US, talked a 
doctor into doing a prophylactic appendectomy on the grounds that her 
particular circumstances warranted it, and reported back to the researcher 
that she'd had her appendix out.  He said "What?"; she reminded him that 
he'd told her to do it, and he said "Oh, that was just to see how dedicated 
you were.".

Kevin "vestigial human" T. Keith