Educating the Public - The Philadelphia Project and others

appendicitis time


Most patients in the Emergency Department who come in with appendicitis have self diagnosed, and have known to come to the hospital. These patients are all uniformly certain that appendectomy is what they need "before the appendix bursts." The first question asked in the family waiting area after surgery is "was it ruptured?" And there are instances, such as a badly ruptured appendix with an abscess, where it is better to place a drain, treat the infection, and then take out the appendix sometime down the road. When that occasion arises, and a surgeon tells the patient and family that there is appendicitis, but it is not advisable to remove the appendix at this time, the family uniformly looks at the surgeon as if he had three heads.

king surgery 1

The signs, symptoms, and treatment of appendicitis are deeply ingrained in our "common wisdom" as a people. Virtually everyone knows about appendicitis and appendectomy. People who are hard pressed to properly brush their teeth, get a mammogram, or stop smoking because of the risk of lung cancer, are all aware that pain in the right lower quadrent of the abdomen should be evaluated by a doctor. And this surety is about a condition that was only described 125 years ago. This universally accepted wisdom is the product of an extensive and ongoing public education effort dating back to 1902.

The King's appendix.


Appendicitis was discussed prior to 1902, to be sure. But in June of 1902, the King of England, Edward VII was due to be crowned, and in the week before his coronation he developed appendicitis with an intraabdominal abscess. (See "The King's Appendix" exhibit) The mortality rate for surgery for appendicitis at that time was around 40%. The King's surgeon and anesthesiologist were ennobled prior to the surgery, in case the King died so they would not be blamed. The coronation was postponed, and the King underwent surgery. The circumstances, dramatic as they were, were naturally covered in exquisite detail in newspapers around the world. The consulting surgeons, including Joseph Lister posted regular updates, which the newspapers greedily printed. At right is the clipping from the Times (London).

After the King survived, appendicitis became an enormously fashionable disease. The numbers of appendectomies done in the UK and in the United States increased roughly ten-fold by 1905. As experience was gained, and because people were being seen earlier for appendicitis, before rupture and sepsis, the mortality rate for appendectomy dropped precipitously from 40% before 1900 to 5% by 1910.

There can be no question but that the appendicitis of King Edward VII, and his good outcome from surgery saved countless lives over the past 110 years.


The Philadelphia Project

John B. Murphy is memorialized in this museum in the John B. Murphy Hall for diagnosis. Dr. Murphy was a colorful surgeon, who was an innovator, a brilliantly innovative technical surgeon, and a forceful advocate for early removal of acute appendicitis. He died in 1923, and the torch for educating the public about appendicitis was carried on by surgeons around the country through the activities of the American College of Surgeons.

By the 1930's there was concern that the mortality ofappendicitis was rising. Remember that there were no antibiotics, but that the field of public health had progressed enough to track causes of death. John Bower, a surgeon in Philadelphia, and others developed a plan for increasing the early treatment of appendicitis, and for improving the overall care of patients with appendicitis, thereby lowering the mortality from the disease.

The Philadelphia group developed their plan around three developed goals,

1. Improve the education of the people of the possible seriousness of pain in the abdomen, especially in the young.

2. A campaign in the medical profession on the necessity of immediate hospitalization of patients suffering with pain in the abdomen where a tentative diagnosis of appendicitis is made.

3. Standardization of the type of treatment to be offered for appendicitis.

philadelphia placard

The group then persuaded the Philadelphia Association of Retail Druggists to place warning placards up in every Pharmacy in the city, warning people of the symptoms of appendicitis (see to the left).

An ensuing education program with the retail pharmacists was begun, to achieve the desired goal of pharmacists not recommending laxative or emetics for abdominal pain (shades of "rebalancing the humors" still practiced). This effort quickly went national, and by 1934 insurance companies were running ads in magazines, such as the one pictured at the top of the page from Time magazine.

appendicitis cartoon

Time magazine 1934

As Bower reported in 1940, the death rate from appendicitis dropped significantly as a result of these efforts. That right lower quadrant abdominal pain might be appendicitis was firmly planted in the popular consciousness. That you should see a doctor for abdominal pain, and not take laxatives became a mandatory part of children's education. (I remember this from my elementary school Health classes.)

Madeline!

In 1939 Ludwig Bemelmans, an Austrian artist, published the classic children's book, Madeline. In telling the story of the young girl living in a Parisian boarding school, Bertelsmas has captivated generations. And he does a good bit of educating as well.

madelines appendix

When Madeline develops abdominal pain, and is crying in bed, the headmistress immediately summons the doctor. She is not given purgatives or any other treatment. Miss Clavell immediately suspects the problem and treates Madeline appropriately, by having her evaluated by a physician.

Madeline is seen by the doctor who immediately diagnoses appendicitis, and who alerts the hospital. Madeline is rushed to the hospital in an ambulance, and undergoes immediate surgery.

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Madeline, of course does well and recovers from surgery well enough to be showing off her scar to her admiring friends very quickly.

Madeline's popularity as one of the highest selling children's books of all time has quietly educated generations of children since 1939 about the signs, symptoms, and proper treatment of acute appendicitis, as well as that surgery is not so scary or as painful as they might believe.