The Roentgen-ray Diagnosis of Inflammatory Disease of the Appendix

Abstract

ALTHOUGH much has been written concerning the roentgen-ray diagnosis of disease of the appendix, in this paper no attempt is made to review this material, for the reports here are based only on independent, personal observation. I have no doubt that many others have based their diagnoses on similar criteria. Within the past month Moore and Merritt2 have described some of the same findings. Carman, in his book, “The Roentgen Diagnosis of Diseases of the Alimentary Canal,” placed special emphasis on an article by Spriggs and Marxer in The Lancet of 1919. This has undoubtedly formed the basis for much of the best work that has been done in roentgen diagnosis of disease of the appendix. That all of the criteria advanced have been more or less unsatisfactory and unreliable is evident from the multiplicity of methods described, none of which has come into general use. Many surgeons of experience are hesitant to operate in cases in which a diagnosis of disease of the appendix has been made roentgenographically, evidently because previous experience has shown that these findings are unreliable. These same surgeons know that the results of appendectomy in some cases of so-called chronic appendicitis are brilliant, but in a much larger group they are unsatisfactory. Because of this experience they recognize a real need for a type of examination that is dependable and will indicate with reasonable certainty the cases in which surgery is a consideration. I do not believe that this is true of any of the methods now in common use. What are the indications for surgical intervention in disease of the appendix? In my opinion this must be answered from two viewpoints, the first being active inflammatory disease, and the second, mechanical disturbance resulting from previous inflammation in the appendix or other closely related structures. In active inflammation three grades are generally recognized, acute, subacute, and chronic. The characteristics of acute appendicitis are well known and do not require repetition. Spontaneous healing may take place or serious complications result. Subacute appendicitis may be a stage of subsiding acute appendix, which may later be followed by complete healing. On the other hand, there is evidence pointing to the fact that the stage of subacute inflammation may continue over a period of months or possibly years. The term “chronic appendicitis,” a loose one, generally covers any long-standing abnormality of the appendix due to active low grade infection or the result of previous infection. In the above classification it applies only to low grade, active inflammation. It may be a late stage in a subsiding acute appendicitis which will go on to complete repair, or it may continue as a low grade inflammatory condition for years. The indications for surgical intervention in the acute cases are generally recognized. In subacute appendicitis they are not so clear, probably because accurate diagnosis is much less certain.