Appendicitis in Bristol—100 Years Ago

In Volume 4 of the Bristol Med-Chi Journal (1886)1 we find a report of a 13 year old boy who developed abdominal pain in the right iliac fossa. He was anorexic, had vomited and was noted to be pyrexial; examination revealed tenderness localised to the right iliac fossa. Treatment was conservative with turpentine, castor oil and local poultices. When he failed to improve over the next three days, belladonna and laudanum was administered for pain. On the fourth day his pyrexia was resolving but he had a 'tendency to coldness of the extremi-ties'; he died on the morning of the fifth day. A post mortem demonstrated lower abdominal peritonitis and a friable appendix containing a faecalith. The diagnosis made on this unfortunate boy was typhlitis and the treatment prescribed by J. G. Swayne, who later became the Professor of Surgery in Bristol, was standard for this time. In the same year, 1886, the first meeting of the Association of American Physicians in Washington DC was addressed by Reginald Fitz2. His classic paper on 'Perfor-ating inflammation of the vermiform appendix; with special reference to its early diagnosis and treatment' contained the first mention of the word 'appendicitis' and made two important observations. Firstly he emphasised that most inflammatory disease of the right iliac fossa commences in the appendix, and secondly he urged early surgical intervention. Although neither of these points were entirely new, together they delivered a powerful message which the American surgeons were quick to exploit with a rapid fall in the mortality rate from appendicitis. The conservative British surgical establishment was slow to follow and surgery was usually delayed until crepitus was apparent. In this article I will attempt to explain the events that led up to this change in practice.