THE DIAGNOSIS OF ACUTE APPENDICITIS

To see an article entitled "The Lucid Interval and Acute Appendicitis" is to have our interest immediately aroused, for we at once wonder whether the author is referring to appendicitis in the insane. We can hardly believe that he refers to the mental state of the medical attendant. Perusal of an article with the above title by John O. Bower shows that by "lucid interval" he means the period preceding perforation of the appendix, with its inescapable sequence of peritonitis, during which signs and symptoms temporarily disappear.' The name "lucid interval" is borrowed from the corresponding hiatus in the clinical history of a patient suffering from traumatic extradural hremorrhage, and though the choice of English is questionable, the value of emphasizing the importance of this interval is undoubted. As the author remarks, a patient may be sent to hospital with a diagnosis of acute appendicitis, but on arrival apologizes to the hospital staff for his symptom-free state, and quotes the familiar parallel of the aching tooth which is cured by entering the dentist's door. We must further agree that if the surgeon accepts the diagnosis, perhaps largely on the history and on his confidence in the clinical acumen of the practitioner who saw the patient earlier, a catastrophe may be prevented. Bower traces the pathological history from the supposed obstruction of the lumen of the appendix either by a frecolith or by a mucopurulent plug through the successive changes in the mucosa and submucosa, with swelling and local necrosis, to the devitalization of the hitherto intact muscularis and serosa, and thence to rupture. He points out the all-important factor of intraappendical tension in the causation of pain, and indicates the likely reasons for the cessation of pain. These are the devitalization of nerve terminals and the escape of gas and infectious material from the lumen of the appendix into the bowel, with a consequent reduction in vascular congestion. The action taken by a surgeon in this interval period is of the utmost importance. He can, of course, choose between two paths: that of immediate action and that of inaction. But if he takes the latter course, it is essential that he follow, at least for a time until observation has convinced him of the exact state of affairs, a routine similar to that laid down in the Sherren-Ochsner treatment. Bower tabulates the points likely to be found helpful in the diagnosis of the pre-perforative stage of acute appendicitis. These include a complete history, a thorough physical examination, the careful evaluation of the findings of any other doctor who has examined the patient, and a differential leucocyte count. The history must include full information as to the amount of aperient or opiate which may have been administered, and the author quotes again the truism that colicky pain, at first central and later local, is still the most reliable early symptom of inflammation of the appendix. In discussing the second point he remarks that the significance of tenderness is not sufficiently appreciated by the average physician. We hope this statement is not true, but