To the Editor.
—Dr Wagner and colleagues are to be congratulated on a thorough review1 of the clinical diagnosis of appendicitis. However, there are several statements with which we disagree. The test for rebound tenderness is advocated for diagnosing general or localized irritation of the peritoneum, but the diagnostic accuracy and patients' acceptance of the test have been questioned.2,3 The authors recommend performing the test for rebound tenderness by gradually compressing the abdomen and underlying peritoneum and then "without warning, and preferably while the patient's attention is distracted, remove the hand suddenly to just above skin level. Watching the patient grimace is more indicative than a complaint of pain." In our opinion and that of others, this test is somewhat sadistic and often provides no additional information in patients who clearly have peritonitis based on gentler examination techniques. A gentle examination technique is essential in eliciting abdominal guarding, which is the