Spare Parts Read online

  Burkitt and Trowel’s belief in the benefits of a “primitive” diet rich in dietary fiber vs. the lower fiber, higher fat “Western diet” appeared to be confirmed in communities other than the ones they saw in Africa. For four years, between 1979 and 1982, a team of researchers from the University of Southampton (UK) toted up the number of people discharged after an emergency appendectomy in England, Ireland, Scotland, and Wales. Examining their subjects’ customary diet, the scientists concluded that appendicitis was more common among those who ate lots of potatoes, sugar, meat, and cereals than among those who ate lots of fruit and vegetables other than potatoes. Obviously, the scientists knew that the ultimate cause of appendicitis was an infection due to the “invasion” of bad bugs, but the fruit-and-vegetable regimen appeared protective.36

  After that, for another fifteen years or so, everyone assumed that Burkitt’s theory had settled the question: foods high in dietary fiber lowered the risk of appendicitis and colon cancer, and they also seemed to protect the heart. Colon cancer is a more serious killer than the appendix. The first carries off about 59,000 Americans each year; diseased appendixes, including cancerous ones, eliminate fewer than 500. So, protecting the colon became the raison d’être for eating lots of the veggies and fiber-rich foods now presumed to ward off the disease. But in 1999, data from the long-running Nurses Health study at Boston’s Brigham and Women’s Hospital and Harvard’s School of Public Health said, “Not so fast.” The nearly 90,000 women in the study had been asked to keep records of their daily diet, sometimes for as long as sixteen years. At the end, the evidence was right there in black and white, or whatever color ink the women chose. Those who ate lots of fibrous foods were no less likely than those who didn’t to develop colorectal cancer or polyps, possible precursors of the cancer. ‘ “We really can’t substantiate a protective effect of fiber on the rates and risk of colon cancer,’’ said Dr. Charles S. Fuchs, a medical oncologist at Brigham and Women’s and the lead author of the study. ‘ “That is not to say that fiber is not a good thing. It is still helpful, but not for colon cancer.’’37

  The need to resolve that uncertainty led to the four-year Polyp Prevention Trial conducted under the auspices of the National Cancer Institute at eight sites known collectively as the Polyp Prevention Trial Study. The program enrolled men and women who had undergone colonoscopy within the previous six months and been diagnosed with a colon polyp (a possible precursor of colon cancer) that was removed. Half these volunteers were told to eat what they normally did; the other half were asked to follow a low fat, high fiber diet with lots of fruits and vegetables to see whether doing that might prevent a recurrence of polyps. It didn’t. The recurrence rate was the same for both groups.38

  But, “No sale is ever final.” So there was a second go-round, the Wheat Bran Fiber Study, to evaluate the protective potential of the specific dietary fiber in grains. Once again the volunteers were people who had been diagnosed with and relieved of a colorectal polyp, this time within the previous three months. Half were asked to add a cereal supplement high in wheat bran to their daily diet, half were given a cereal supplement low in wheat bran. The study, funded by the National Cancer Institute and run at the Arizona Cancer Center (Tucson) by the Phoenix Colon Cancer Prevention Physician Network, produced the same conclusion as the Nurses study and the Polyp project. It showed that consuming lots of dietary fiber doesn’t reduce the risk of recurring polyps or the risk of colorectal cancers.39 But, the study authors concluded, “the abundance of data indicating that a diet low in saturated fats and rich in fruits, vegetables, and whole grains has a favorable influence on the risk of chronic disease and mortality; it seems appropriate that this type of diet be promoted on the basis of its known healthful effects.”40 In other words, no sale is ever … so, yes, all the scientists and institutions involved plan to continue to study the effects of dietary fiber on intestinal health.

  Meanwhile, back at the appendix, remember, that sentence about how the true cause of appendicitis was an infection? The idea of appendicitis as an infection isn’t new, of course. What is new is that examining how the infection happens opens a whole new window through which to view this once “useless” organ.

  Good bugs, bad bugs, and your appendix. The mid-19th-century introduction and growing acceptance of the germ theory made it possible to solve the mystery of contagion and to demonstrate, as Theodore Rosebury cheerfully explained in his classic Life On Man (1969, The Viking Press), that our bodies teem with colonies of infinitesimally small organisms that both protect and threaten us, sometimes at the same time. This microbiome (universe of microorganisms) thrives on our skin and in our respiratory passages as well as in our intestinal tract, where its members diligently plug away at mundane housekeeping tasks such as extracting nutrients from food and consolidating waste. Ordinarily, friendly microbes are in charge, but from time to time, the not-so-friendlies gain the upper hand, causing gastric havoc.

  In 2007, a team at Duke University Medical Center led by William Parker, assistant professor of experimental surgery, and R. Randal Bollinger, professor emeritus in general surgery, proposed the intriguing possibility that the appendix is a place where the beneficial bacteria go to hide during intestinal disorders such as diarrhea or cholera. These beneficial bugs wait until the intestines are free of disease organisms and then emerge to repopulate the gut and reestablish the favorable balance of good to bad bugs.41, 42 Four years later, a survey of patients at Winthrop University Hospital on Long Island (New York) appeared to support this proposition of the appendix as a guardian organ. Among 254 patients with a history of Clostridium difficile (a.k.a. C. difficile or C. diff ), an intestinal upset sometimes acquired during a hospital stay, those without an appendix were more than twice as likely to suffer a recurrence.43

  Sandwiched in between these studies was one suggesting that appendicitis might actually be a viral infection like the flu. When pediatric surgeon Adam C. Alder and friends looked at discharges from American hospitals in the thirty-six years from 1970 to 2006, the University of Texas Southwestern Medical Center team discovered that while appendicitis seemed to be more common in the summer, overall the incidence of nonrupturing appendicitis rose and fell with peaks similar to those produced by influenza epidemics. No one tried to pin appendicitis on the flu virus, but their report in the January 2010 Archives of Surgery did raise the possibility that the influenza virus may make the immune system less able to ward off an “as-yet-unidentified” appendicitis virus. Three years later, the Archives of Surgery published a review of hospital discharges in the United States (1970 to 2006) suggesting that the incidence of nonrupturing appendicitis mirrors the incidence of influenza, feeding this speculation.44 Therefore, consider the still theoretical but entirely realistic possibility that your appendix is an important part of your immune system. As Loren G. Martin, professor of physiology at Oklahoma State University, wrote in Scientific American: “Among adult human beings, the appendix is now thought to be involved primarily in immune functions. Lymphoid tissue begins to accumulate in the appendix shortly after birth and reached a peak between the second and third decades of life….Thus, the appendix probably helps to suppress potentially destructive humoral (blood and lymph-borne) antibody responses while promoting local immunity.”45

  Finally, there is a simple but completely unproven physical explanation for a troubled appendix. Everyone knows that our senses of taste and smell are linked to the tongue and the nose. But our senses are rooted in our brain, and our nervous system is connected to our intestines, so closely that some have called the digestive system a “second brain.” These nerves govern peristalsis, the contractions that move food through your body and that may or may not play a role in keeping the appendix healthy and managing to stave off appendicitis.

  But in the end, there really is no conclusive explanation for appendicitis, which, though fairly common, remains, says UT Southwestern’s chief of GI/endocrine surgery Edward Livingston, “a frustrating my
stery.”

  AFTER WORDS

  The inquisitive, self-assured Leonardo da Vinci and Michelangelo began our journey towards the sure and steady understanding of our bodies, leading eventually to Paul Segond’s 21st century conclusion noted way back in the Introduction to this book that we still don’t know everything there is to know.46

  In 1859, Charles Darwin labeled the appendix vestigial, and ever since then people have translated that as “useless.” But contrary to common wisdom, this small organ has been pivotal in the history of medicine. First seen by ancient Egyptian priests preparing the dead, it remained hidden from western eyes for several thousand years, emerging only when autopsy became common and Italian Renaissance artists and anatomists defied the Church prohibition on human dissection to discover what Leonardo da Vinci called the “little ear” at the junction of the small and large intestine. Once identified, the appendix played a leading role in the development of surgical medicine at the end of the 19th century. Today it figures in our exploration of the gastrointestinal system and our immune function, and pragmatic surgeons have used it to replace a damaged ureter.

  And finally circling back to Darwin, the unassuming, underestimated, underacknowledged appendix remains a centerpiece in our understanding—sometimes misunderstanding—of human evolution, feeding nutritious food to those who argue that everything we have is worthwhile having, which, for once in the Evolution Debate, includes both sides.

  On the one hand, from the scientists:

  “The evolution of the appendix was not an accident…. Researchers analyzed relatedness of the 50 out of 361 living mammalian species that have appendices. They found that the appendix had evolved independently 32 to 38 times and was lost only seven times, making it likely that it evolved for a reason. The purpose of the appendix remains a mystery, however.”47

  On the other hand, from those who opt for creationism:

  “How times have changed. Even using evolutionary assumptions, the appendix cannot be a degenerate evolutionary structure. Furthermore, various lines of evidence have pointed increasingly to the appendix playing an important role in the immunological control of organisms in the gut. A functional organ, therefore—working in tandem with the many other functional organs in the body, all of which is consistent with having been creatively designed by the biblical Master Designer (Psalm 139:14, Romans 1:20).”48

  Surely, no body part that can compel agreement from two such different camps can be considered useless.

  THE APPENDIX

  A brief timeline of discovery,

  diagnosis, & treatment

  ca 3000BCE Egyptian priests performing mummification identify the “worm of the intestines”

  1492 Leonardo da Vinci finds and draws the appendix which he calls “little ear,” but the illustration is not published until several hundred years later

  1521 Absent da Vinci’s drawings, Italian physician and Renaissance anatomist Jacopo Berengario da Carpi is credited with being the first to describe the appendix

  1544 Jean François Fernel, the French physician who coined the term “physiology,” describes appendicitis

  1561 Gabriele Falloppio (Fallopius) appears to be the first Western writer to refer to the appendix as a “worm”

  1735–1736 British military surgeon Claudius Amyand announces having performed first appendectomy

  1759 Bordeaux physician Mestivier describes perforation of the appendix and names it as the cause of the resulting abscess

  1812 British surgeon John Parkinson describes an autopsy of a five-year-old child showing a fecalith (a hardened mass of feces) in the appendix

  1827 After eight autopsies of patients with obstructed appendixes, French physician François Melier proposes surgery as a treatment for diseased appendixes, a suggestion dismissed by his superiors at Paris’s Hotel Dieu.

  1830 Gottfried Goldbeck at the University of Geissen (Hesse, Germany) says an infected appendicitis, which he calls perityphilitis is due to an inflammation in the nearby cecum.

  1846 Adolph Volz names the appendix as the cause of inflammation in the right lower quadrant of the abdomen

  1885/1888 English surgeons Charter Symonds (1885) and Frederick Treves (1888) each claim to have performed the first “interval” appendix surgery

  1886 Reginald Heber Fitz, Dean of the University of New Mexico School of Medicine, introduces the term appendicitis and, like Melier 60 years before, recommends early surgical intervention

  1889 Charles McBurney, chief surgeon at Roosevelt Hospital in New York City, identifies “McBurney’s Point” as the site of abdominal tenderness due to appendicitis

  1898 American anatomist and surgeon August Charles (A.C.) Bernays reports having performed 71 appendectomies without a fatality

  1904 John B. Murphy, surgeon and one-time president of the American Medical Association, claims two thousand successful appendectomies

  1925 Arthur Rendle Short, professor of Surgery at Bristol University (UK), suggests that appendicitis may be a “disease of Western civilization” due to an “advanced” low-fiber diet

  1983 German surgeon Kurt Semm, the “founder of laparoscopic surgery,” performs the first fully laparoscopic appendectomy

  2007 Duke University researchers suggest that the appendix may serve as a “safe house” for bacteria in the human gut

  2010 Surgeons at the University of Texas Southwestern Medical Center (Dallas) announce a possible link between viral infections and appendicitis

  2011 Winthrop University Hospital (New York) gastroenterologists release data showing that an intact appendix may protect against recurrence of the intestinal infection C. difficile

  2014–2015 Researchers at a number of American hospitals and universities suggest that in “uncomplicated appendicitis,” antibiotics may be a reasonable alternative to surgery

  2

  Feathers & Fur

  Body Hair

  “Of all the types I’ve ever met within our democracy

  I hate the most the athlete with his manner bold and brassy

  He may have hair upon his chest but, sister, so has Lassie.”

  —Cole Porter, “Kiss Me Kate” (1949)

  “Man differs conspicuously from all the other primates in being almost naked. But a few short straggling hairs are found over the greater part of the body in the man, and fine down on that of a woman. The different races differ much in hairiness; and in the individuals of the same race the hairs are highly variable, not only in abundance, but likewise in position: thus in some Europeans the shoulders are quite naked, whilst in others they bear thick tufts of hair. There can be little doubt that the hairs thus scattered over the body are the rudiments of the uniform hairy coat of the lower animals. This view is rendered all the more probable, as it is known that fine, short, and pale-coloured hairs on the limbs and other parts of the body, occasionally become developed into ‘thickset, long, and rather coarse dark hairs,’ when abnormally nourished near old-standing inflamed surfaces.”

  —Charles Darwin, The Descent of Man

  THE NATURAL NATURE OF OUR HAIR

  The words glade and clade have two things in common. Both contain the four letters l-a-d-e and both have something to do with trees. A glade, from the Norse glaðr meaning bright, is an open space surrounded by real ones. A clade, from the Greek word klados meaning branch, is an offshoot of “the tree of life,” a scheme anthropologists use to classify groups of living things descended from a common ancestor.

  THE TREE OF HUMAN LIFE

  Our human history begins with the “super family” Hominoidea (tailless Old World monkeys living in Africa and Southern Asia) and then after many millions of years evolves to the tribe of Homini, at which point our branch, Homo, separates from our closest relatives, the chimpanzees (Pan).1 How close are we and they? In 1973, in her doctoral dissertation, University of California Berkley geneticist Mary-Claire King said that we and the chimps shared 99% of our DNA.2 Thirty-two years later, an international team of sixty-se
ven scientists led by Robert Waterston, director of genome sciences at the University of Washington (Seattle), mapped all the chromosomes in the body of a chimpanzee named Clint. Comparing Clint to us, they lowered the estimate of our shared DNA to a still-impressive 96 percent, a difference ten times smaller than that separating a common mouse’s DNA from a common rat’s. As Emory University primatologist Frans de Waal, director of the Living Links Center at the Yerkes National Primate Research Center, says, “Darwin wasn’t just provocative in saying that we descend from the apes. He didn’t go far enough. We are apes in every way.”3, 4

  Well, maybe not in every way, but one thing we certainly have in common is body hair. You might have to use a magnifying glass to see it, but anatomists know that every one of us, male and female, has as many hairs on our body as a chimpanzee has on his or hers. The difference between us and the apes is that most of our hair from neck to belly button is often so fine as to be virtually invisible, although there may be differences due to gender and ethnicity.