There is a certain pleasure in having your prejudices overturned, at least when they are not essential to the whole of your mental economy. It reassures you that you are still a rational being, and not one who believes what he believes simply because has always believed it, and what he has always believed must be right.
Until the publication of the British Medical Journal of April 5, I strongly believed that the operation of appendectomy (known in Britain as appendicectomy) was essential for the condition of appendicitis. If the patient did not have the operation, he would suffer dangerous complications such as perforation and then peritonitis. True, I had not given a lot of thought to the question since I was a very young doctor, but it was what I had been taught in good faith by eminent men and so I continued to believe it.
The paper in the BMJ performs what is known as a meta-analysis of randomized controlled trials of initial treatment of uncomplicated appendicitis (that is to say, without evidence of rupture or peritonitis) with antibiotics compared with operation. There have been four such trials whose results were pooled in the meta-analysis, and I must say that I admire the courage of those who conducted these trials considering how strongly entrenched the necessity for operation is in most doctors’ minds (and, I suspect, in patients’ minds too).
The results favored initial treatment with antibiotics rather than immediate operation. The interpretation of those results was complicated slightly by the fact that if people with appendicitis did not improve within two days of antibiotic treatment, they went on to surgery regardless; nevertheless, at least two thirds of people with appendicitis were cured by antibiotics alone. Overall, they had a lower rate of complications than those who were operated upon straight away on diagnosis.
This finding is all the more significant because a high proportion of appendectomies prove to have been performed on appendices that were not inflamed and whose removal was not necessary. And while it is true that abdominal surgery these days carries far fewer risks than it once did, it is still not entirely without risk. No one would have his innards poked-about by a surgeon for the mere fun of it. In other words, if this meta-analysis is to be believed, the first-line treatment of appendicitis (without evidence of complication) ought to be antibiotics.
The paper does not mention the curious history of appendicitis, whose incidence rose steeply in the Western world from the end of the nineteenth century to the middle of the twentieth, and then declined — for example, by a half in England between 1960 and 1980, and then yet further. The explanation for this is uncertain and contested.
When, a few decades ago, I thought of joining an expedition to the Antarctic as a doctor, one of the qualifications for the post was a willingness to have one’s appendix out in advance (I decided in the end that I didn’t like the cold enough to go). And I remember the story of a Soviet navy doctor aboard a nuclear submarine who was obliged to operate on himself for appendicitis by means of a system of mirrors. It all seems rather passé now: he could just have set up some intravenous antibiotics for himself.
If I were to get appendicitis now, would I want antibiotic treatment or operation? I should certainly advocate antibiotics for everyone else but for myself… even though I have overthrown my prejudice, I think I would still want an operation because that is what the correct treatment was in my younger days. Curious, is it not?
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