The Appendicitis Analogy and Iraq

Or be thankful you are not the President

 

By Richard R. Grayson, M.D.

 

Geneva, Illinois

 

This paper is not about appendicitis, but is about the alleged failure of the United States government to correctly diagnose the pathology of Iraq and of Saddam Hussein’s mind before declaring war.

 

What has the diagnosis of appendicitis to do with the decision to invade Iraq?   The correct evaluation of such a simple disease by the most ethical, educated, brilliant community in the world, the practicing physicians of the United States, does not produce a perfect diagnosis in every case.  How can we hold others to a higher standard?

 

When I graduated from the University of Illinois Medical School in 1948, we had a dictum.  The rule was that if the surgeon did not find a normal appendix in 10 percent of the cases diagnosed pre-operatively as acute appendicitis, he was not operating often enough.  He must have been missing some cases of acute appendicitis. In other words, a patient can have right lower quadrant pain, rebound tenderness, nausea and vomiting, an elevated white blood cell count, and still not have appendicitis. I specifically remember cases of cecal diverticulitis, cancer of the cecum, gastroenteritis, ruptured ovarian cyst, ovarian follicular rupture, renal colic, acute salpingitis, tubal pregnancy, Meckel’s diverticulitis, cholecystitis, and even black widow spider bite as confounding diagnoses.

 

More than 50 years have passed and we have modern technology not even dreamed about when I was young.  Things must have changed. So I looked it up.  Things have not changed. The following three citations are my evidence:

 

“In 1997, 261,134 patients underwent nonincidental appendectomies in the United States. However, 39,901 (15.3 percent) of the appendixes removed showed no pathologic features of appendicitis” ( http://www.aafp.org/afp/20050101/71.html )

 

“Approximately 290,000 patients in the United States underwent urgent appendectomy in 1999. A normal appendix is removed in up to 40 percent of patients who undergo surgery because of a preoperative diagnosis of appendicitis. Several studies have reported improved diagnostic accuracy with the incorporation of computed tomography (CT) into clinical decision-making, but other studies have failed to replicate these results.”

( http://www.findarticles.com/p/articles/mi_m3225/is_8_68/ai_108993983 )

 

“More than 250 000 Americans, 1/4 to 1/3 of which are children, undergo appendectomy annually for the presumptive diagnosis of acute appendicitis.¹ Although appendicitis evidence-based guidelines reduce variability and control costs without sacrificing quality,² sadly, they are used by only a fraction of practicing physicians.³ In the recent past patient and societal costs for the 15% "negative" appendectomy and the 33% perforative appendicitis rates were substantial.¹     PEDIATRICS Vol. 113 No. 1 January 2004, pp. 130-132” ( http://pediatrics.aappublications.org/cgi/content/full/113/1/130-a )

 

All right, medicine is still an art and not a science. How many million times have I heard that over the years?  I have not heard any malpractice attorneys using that argument as a defense lately. It seems that the new view of the practice of medicine is that it is a science.  I wish it were so; we all would live forever and there would be no malpractice suits.

 

What does this have to do with current world events?  Is governance a science?  What about the war?  Was there a conspiracy by an evil cabal? Did the government make a mistake? Was it justified?  Were there weapons of mass destruction ready to be deployed against us?  I maintain that the symptoms of the problem were present and it was the duty of the surgeon/president to do his duty and to operate. And furthermore, so far as can be known, his consultants agreed.  I realize that roughly half the population of this country disagrees with me, and has the most vitriolic calumnies to say about George W. Bush, Dick Cheney, Paul Wolfowicz, Don Rumsfeld, Condaleezza Rice, Colin Powell, and others.

 

Then there is a group who place all the blame on the president, calling him a dictator. For example, one of my intellectual friends had this diatribe: “….when one is enjoying a 50 million dollar three day ostentatious blast to honor the inauguration of a paranoid demagogic war president….”, which followed another blast: “…What I do know is he lied to the congress and to you and to me just to justify launching a deadly war against a poorly perceived or understood foe just because he and a few friends thought it was good idea to spread good ol' American joy around.”

 

Another of my scholarly coterie exploded with this: “The moment George Bush refused to go spill blood in Vietnam may have been the moral Everest of his life. But he has long since buried that singular act of conscience beneath a stench-heap of warped psychological projection and ethical hypocrisy. The president remains a stunted brat and a coward at the core, dodging rules he forces others to abide by with unforgiving strictness. Festooned in a flight jacket he never deserved, Bush has ordered National Guard troops into a bloody desert war he and his chicken hawk cronies launched under fabricated pretexts. Then in order to hand out tax breaks to the super-rich and billion-dollar contracts to favored arms makers, Bush scrimped on the funding of his precious war itself: too few troops, under-armed, over-worked, and operating with no occupation plan and no exit strategy.”

 

Meanwhile let’s consider the appendicitis analogy. All the intelligence agencies of the world agreed that Iraq had weapons of mass destruction, like Saran gas, Anthrax by the barrel, and would have nuclear soon.  Recall Resolution 1441 by the United Nations, which ended with this sentence: “the Council has repeatedly warned Iraq that it will face serious consequences as a result of its continued violations of its obligations;”

 

Consider also the relevant words of the U.S. Senate resolution of October 11, 2002, passed by 77 of the 100 Senators after a similar bill passed the House of Representatives: “The president is authorized to use the armed forces of the United States as he
determines to be necessary and appropriate in order to (1) defend the national
security of the United States against the continuing threat posed by Iraq, and (2)
enforce all relevant United Nation Security Council resolutions regarding Iraq."

”The resolution requires the president to notify Congress within 48 hours of any
military action against Iraq and submit, at least every 60 days, a report to Congress
on the military campaign.”

 

The United States Congress declared war on Iraq and authorized the president as Chief Executive Officer, to protect the country from a pestilence which had all the lethal earmarks of a plague, which he did. Likewise, the doctor proceeds to operate for acute appendicitis, not for evil reasons, but because he has to operate.

 

My fellow physicians will go to work tomorrow and make thousands of judgments, get thousands of expert consultations, order millions of tests, and sometimes the syndromes won’t match the prescriptions.  Sometimes there will be a normal appendix in a patient when everyone knew it was appendicitis.

 

Remember just one thing tomorrow morning as you go on your appointed rounds: be thankful you are not President.

 

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