Scapegoats of our being

When we examine the belly of patients with abdominal-pain, we are taught to carefully look for scars. These convey important information. Interestingly, scars also bear testimony to several cultural and surgical trends of certain periods of history.

Sanjay Nagral
Oct 23, 2020, Mumbai Mirror

When we examine the belly of patients with abdominal pain, we are taught to carefully look for scars. These convey important information. They could mean that there are ‘adhesions’— a phenomenon after surgical procedures where structures get stuck to each other as a reaction to the surgical trauma. Or, they could be sites for weakness in the abdominal wall called hernia. Sometimes, the previous operation is directly the cause of pain. Interestingly, scars also bear testimony to several cultural and surgical trends of certain periods of history.

One scar which used to be common in certain poor communities was the ‘branding’ mark, a practice in which the skin is burnt in the belief that this alleviates pain of any sort, conveying a long-standing painful condition. In women, the small scar of a tubal ligation near the umbilicus bears testimony to a period in India’s history when a ‘family planning’ operation on women of a certain age was almost like a national duty. Again in women, lower abdomen scars of caesarean sections or hysterectomies are common. There is evidence of low thresholds in offering these procedures in the subcontinent, of biases, excesses. Scars are a threat to getting married but acceptable afterwards.

There is another scar in the right lower abdomen. When asked, “What was this scar from?” many reply, “I think the appendix was removed”. When asked, “Why?” there are a variety of answers from “pain” to “some abdominal problem” to “Don’t know”. The patient can’t be blamed. The reasons for removing the appendix till a few decades ago were nebulous—chronic pain in the abdomen being one. The appendix, like the tonsil and the uterus, has been treated as an expendable organ, relatively easy to remove. Surgery is also a powerful placebo.

The story of the appendix, its inflammation and removal embodies the quirks, triumphs and hubris of modern medicine. Gaps in knowledge, reversals of previously held beliefs and surprising new understanding have emerged over years. The appendix’s story is also a reflection of the attempt of modern surgery to become objective, less harmful and precise.

In the orchestra of organs that is the human body, the appendix is a wormlike tube jutting out from the junction of the small and large intestine that was for decades thought to be a useless bystander. It was called a vestigial organ—something that became useless in evolution. But while it mostly sat silently, it was capable of sudden mischief by inflammation, and rarely, perforate into the abdominal cavity, causing a life-threatening crisis. It was one of the first human organs to be operated upon. And an appendectomy still remains one of the commonest operations in the world.

Once upon a time, a patient with abdominal pain was examined in a flourish by surgeons who placed their hand on the spot and as the patient winced with pain, proclaimed: “Take the appendix out.” But soon, it was realised that many other diseases mimicked appendicitis, causing severe embarrassment at surgery. In my training days, women with ectopic pregnancies or those with intestinal TB were opened by junior surgeons at midnight with a diagnosis of appendicitis and all hell broke loose.

Then came investigations. Blood tests, ultrasound and CT scan. A CT scan is now considered precise. An interesting development in the 1990s was the creation of scores using combinations of clinical pointers to predict chances of appendicitis. Patients who scored high are operated on. This objective method is now common in medical decision-making. This can be done by computers, and AI-based algorithms are a further extension of such methods.

The ability to peek inside the abdomen with a camera inserted through a small hole, called laparoscopy, gave a big fillip to the efforts at sharpening diagnosis. This is now the standard way to evaluate acute abdominal pain if nothing else helps and the appendix is even removed through it. The scars have become smaller.

The big development of the last decade is the understanding that a majority of attacks of appendicitis can be treated with antibiotics alone. Elegantly performed large trials have shown that in a subset of uncomplicated appendicitis identified by a CT scan, the attack can be treated by antibiotics without hospitalisation. This research comes from surgeons in systems which have no stake in performing a large number of appendectomies. In the rest of the world, this practice has still not been widely accepted, perhaps because surgical volumes are rewarded. During the Covid-19 epidemic, many appendicitis patients were successfully treated with antibiotics because of the scare and unavailability of surgery. This has led to further circumspection on the necessity of removing inflamed appendices.

Finally, in startling new work, the appendix has been shown to perform important functions which can have a bearing on other diseases. It has been shown to be a site of immunity. It has also been shown to be a reservoir of good bacteria or an important part of what is now called the gut ‘microbiome’, whose alterations have been implicated in an astonishing range of diseases, including dementia and mental health problems. There is some early data to show that people who have had an appendectomy have a higher chance of developing Parkinson’s disease.

The appendix has moved a lot in its identity in the human nation—from being vilified as useless to being made the fall guy for many conditions, from being deported with gay abandon and now being tempered with reflective research and appreciation of its role. In the process, a lot of people have been scarred.