OPERATION FOR APPENDICITIS : REPORT OF A CASE.1 
BY EDWIN RICKETTS, M. D., CINCINNATI, O. 
Wm. R. Dabney, aged 20 years, weight 140 pounds, height five 
feet, seven inches, the son of my friend, Dr. D. W. Dabney, of Guyan- 
dotte, W. Va., had his first attack of pain over the region of the appen- 
dix beginning December 5th, 1890, lasting until December 21st follow- 
ing; the pain came on just after a free movement of the bowels; highest 
pulse rate 100; highest temperature 100.5°. No marked distention over 
the appendal region. In this case the McBurney point, as described 
by Dr. L. A. Stimson, held good in this and the following attacks; no 
vomiting in any of the seizures. 
Second seizure began in the latter part of April, 1891, lasting nine 
days, at the end of which time he was sure that he had an escape of pus 
and blood through the urethra. 
Third seizure came on in November, 1891, lasting eight dayt, com- 
plicated with an attack of grippe; temperature touching 104.5°; pulse 
101 to 110; no vomiting, no obstruction. Doctors P. S. Connor, F. 
Foreheimer and B. F. Bebee saw him in consultation. 
Fourth seizure in January, 1892, lasting six days; temperature 100° 
to 101°; pulse going doion to sixty-three, remaining there during the 
seizure; Dr. Connor again saw him; Dr. Forcheimer prescribed ten 
drops of creosote in water, after meals. 
Fifth seizure came on February 18th, 1892, at 6 p. m., when I 
decided promptly to open the abdomen, as soon as I could telegraph 
and get a reply from his father, who resides 160 miles up the Ohio 
Valley. 
The medicinal treatment was the same in each attack, hypodermics 
of one-fourth grain doses of morphia every thirty minutes until the pain 
was relieved, followed by free purgation as the result of salines; while 
during any one of the five attacks there was no distention, no vomiting, 
no obstruction, yet the pain that was so marked at the McBurney point, 
that could be covered on the skin surface by the point of the middle 
fiuger, was simply excruciating, necessitating one-fourth grain doses of 
morphia, hypodermatically every twenty minutes, until four doses had 
been given, before the pain wras relieved. He was purged Saturday 
and Saturday night with Rochelle salts, having had a bath at 9 p. in. 
Sunday morning the abdomen was opened by an incision two and 
one-half inches in length, parallel with the paedian line, the middle of 
which was the McBurney point. The appendix, diseased, distended to 
thrice its normal size, with a tumor the size of a cherry attached to its 
1. Head before the Academy of Medicine, February 29, 1892. outer end, while firmly attached to the gut, was with but little difficulty 
found, and removed by applying a silk ligature within one-fourth inch 
of the bowel, with another half an inch toward the outer end, cutting 
between the ligature, carefully dissecting away the appendix, with its 
tumor, from the intestine. By the application of the ligatures in cutting 
away the appendix, no fluid can escape into the field of operation. This 
field was sponged with warm filtered water, following which the abdom- 
inal wound was closed with Chinese silk twist. After making the 
wound thoroughly dry, two layers of the ordinary absorbent cotton in 
squax*es of six inches were placed over the wound and held in place by 
three strips, two inches in width and twelve in length, of rubber adhe- 
sive plaster. As soon as any moisture of the cotton could be detected 
it was replaced with fresh absorbent cotton. No drainage-tube was 
placed. Anaesthetic, chloroform. Doctors Connor, Bebee, Bramble, 
Hall, Ellis, Mills, Brunning, my brothers and our assistants were present. 
The patient was put to bed, surrounded by copper cans filled with 
warm water. His convalescence has been uninterrupted. But little 
morphia has been given for restlessness or pain. The bowels have been 
kept moving every second day. He has retained nourishment. The 
highest point that temperature has reached was 100.4°, while the pulse 
went up to 100 once. 
We have so many different names given this pathological lesion 
that I choose one—that of appendicitis—which can, for convenience 
and simplicity, be divided into acute and chronic. 
Previous to five years ago statistics would condemn any surgical 
procedure for the relief of appendicitis, save when pus was present, 
evidenced by rigors, sweats, emaciation, rapid pulse and high tempera- 
ture. Even at this time, notwithstanding that the treatment by surgery 
of appendicitis has been revolutionized, we have advocates of medicinal 
treatment in both the acute and the chronic stage; while some say operate 
late, others at the first attack, while some urge an operation from the 
first to not later than the third attack. It took forty years to get the 
medical profession to understand that ovariotomy was justifiable ; now 
we have gone farther, showing that it is not only justifiable, but that it 
should be done before the cyst attains great size. It is seldom that we 
have a primary appendicitis going on to suppuration, but, when once 
the second attack comes on, those that fail to have the third, fourth or 
more attacks are the exceptions to the rule. 
In the case just reported there had been five attacks, and the only 
symptom was pain, and yet, you see, since Dr. Freeman has opened the 
specimen, what serious pathological changes are present. There is no 
pus present. The tumor js gelatinous, containing a few small concre- 
tions. The appendix is markedly thickened. While the patient gives 
a history of an escape of pus and blood per urethra, yet, I am inclined 
to question its coming from this appendix. This early operation, done at such a time, was simple as compared 
with a late operation, done, perhaps, for turning out a pint of pus, in 
which was found partially baked beans, compound cathartic pills, grape 
seeds, etc., etc. 
The diagnosis of acute appendicitis is not difficult, but with an ex- 
tension of the disease, accompanied with marked distension it is very 
difficult. The thermal range cannot be depended on any more than in 
hydro- or pyo-salpinx. McBurney says that it is absurd to depend on 
the thermal range, and yet, this is what guides many a general practi- 
tioner, leading him too often into delaying surgical interference unduly. 
At 7 o’clock of the morning of the operation, my patient’s pulse 
was 63; when on the table at 10 o’clock, following, ready for the anaes- 
thetic, it was 100. Under the anaesthetic it dropped to 65, and there 
remained during the operation. The temperature was 99.5°. 
Weir says, operate as soon as it takes large doses of morphia to re- 
lieve pain. McBurney claims that it is not difficult to determine the 
existence of the disease, but that it is difficult to determine its future 
progress. He is guided by the character and extent of the inflamma- 
tion, and advises operating not later than the third day from the begin- 
ning of the first attack. At present, with thus advocating an opera- 
tion, the concensus of opinion favors doing the same not later than the 
third day. 
A few points bearing on my case, and I am done : This patient, 
having had enough morphia hypodermatically on Friday night to relieve 
pain, was purged Saturday (the day before the operation) with Rochelle 
salts—freely, as we thought—yet, on Tuesday, two days after the oper- 
ation, purging brought away undigested food that had been taken into 
his stomach on Friday, four days previous, just before the attack of 
pain came on. To my mind, this goes to show that “ nervous depres- 
sion,” as the result of the patient knowing that an operation is to be done 
soon, with the added surgical shock, does interfere with digestion. I 
have found that I have made no mistake when I have had my patients 
undoubtedly purged previous to the operation, and then beginning it 
again on the second—not later than the third day. On the following 
Saturday—seven days after the operation—I had to admonish him not 
to do anything more with ice water than to wash out the mouth. After 
having partaken of some sour cream by mistake, he, during the absence 
of the nurse, drank rather freely of ice water, which brought on a vio- 
lent attack of indigestion. From the effects of accumulated gas within 
the stomach and bowels, the abdomen became tense, causing great suf- 
fering. During this attack the pulse was 80, and the temperature was 
98.5°. The Langdon rectal tube was introduced to the length of three 
feet, through which was pumped, by means of the Davidson syringe, 
warm water with soap suds, bringing away scybala and much flatus. 
Relief was soon followed by refreshing sleep. This patient having had more or less morphia since his first attack 
in November, 1890, caused me to have the assistant, Dr. Gillett, admin- 
ister a greater number of hypodermics than I would have done under 
other circumstance*. I dislike its use, following abdominal sections, for 
the reason that it interferes with digestion, constipates the bowels—the 
very things that should be avoided—and, unless the patient is kept under 
its influence continuously, he or she becomes irritable and hard to care 
for. The less morphia, the more satisfactory’the convalescence. 
Had I waited for a rapid pulse, high temperature, obstruction, pos- 
itive evidences of pus from the outside, more tumefaction,with protrusion 
over the appendal region, I am sure that this tumor on the outer end of 
the appendix would have burst, the patient possibly dying of septic 
peritonitis. These violent attacks of pain must have been caused from 
pressure superinduced by the recurring attacks within the appendix, 
and, as a result, the tumor would, in time, certainly have been followed 
by rupture, and I venture the opinion that just such possible ruptures 
are many times the cause of a great number of the so-called attacks of 
“ idiopathic peritonitis.” 
Shall we open these abdomens early for pain alone, when the doing 
in proper hands, in cases that must end in exploration, has a death-rate 
of less than one per cent ? Or shall we wait until the pathological 
lesions are so extensive that a good part of the intestines literally float 
in pus? 
Choose which one you will serve. We can and do have an accumu- 
lation of pus in and around the diseased appendix without a high temper- 
ature and rapid pulse. Don’t let the pain that you are so successful, 
perhaps, in relieving from time to time finally lead you up to a pool of 
pus before urging an operation, for such an operation is very untimely. 
Recurrent localized pain of a severe nature, up to the third attack 
in the appendal region, is enough to show that there must be, within the 
abdomen, a cause for the same, and is in itself enough to demand that 
exploration, as an aid to diagnosis, should not be unduly postponed. It 
is not the thing to take the chances of making morphia fiends out of 
these patients. To explore early, with the possibility of doing a timely 
operation, offers better results than a late operation, done as a last 
resort. If, after three days’ trial in my patient’s first attack, we had 
failed to clear the alimentary tract by salines, aided by the use of the 
Langdon rectal tube, with the hypodermatic use of morphia to relieve 
pain, I would have opened the abdomen promptly.