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127© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2023
S. H. Yale et al., Gastrointestinal Eponymic Signs,
https://doi.org/10.1007/978-3-031-33673-7_5
Chapter 5
Appendicitis: Somatic andVisceral Nerve
Reexes Signs: Mechanisms
andPathophysiologic Approach inAcute
andChronic Disease
5.1 Introduction
5.1.1 Somatic andVisceral Reexes
Physicians identied and reported on various clinical techniques during the nine-
teenth and twentieth centuries to diagnose appendicitis, eponymously named signs,
to honor their accomplishments. These signs provide further support for the bedside
diagnosis of acute and chronic appendicitis and supplement other imagining tech-
niques. Different patterns and locations of abdominal pain in appendicitis are
explained by whether the splanchnic (viscerosensory and visceromotor) and/or
cerebrospinal (somatosensory and somatomotor) nerve pathways are activated.
Activation occurs spontaneously or is expressed through supercial (somatic) or
deep (visceral) palpation [1].
In acute appendicitis early in the disease course, Pacinian mechanoreceptors and
splanchnic afferent nerve bers within the appendix respond to stretch (distension).
The pain bers travel with splanchnic sympathetic nerves through the superior mes-
enteric, gastric, and hepatic plexuses to the dorsal root ganglion. In general, visceral
efferent pain bers, in general, travel along the same spinal cord segments as their
afferent nerve counterparts. Visceral pain is perceived in the midline (epigastric and
periumbilical regions) and is xed regardless of the position of the appendix, reect-
ing its embryologic nerve origin. This pain is generally deep-seated, poorly local-
ized, bilaterally distributed, and more widespread, and it extends to involve the
T8–T10 dermatomes (viscerosensory reex) [1]. What is not widely appreciated is
that in some cases, when visceral pain is abrupt and severe due to rapid distension
of the appendix, there is a “spill-over” phenomenon at peak pain intensity, causing
a direct stimulation of efferent neurons (cerebrospinal nerve pathway) from splanch-
nic afferent nerves due to their anatomical juxtaposition in the dorsal root of the
spinal cord [1]. Thus, abrupt and severe visceral appendiceal pain is perceived
128
within the cerebral cortex as well as causing activation of alpha-motor neurons and
efferent nerve pathways in intercostal nerves that innervate abdominal muscle caus-
ing involuntary abdominal spasm (guarding) in the absence of inammatory
involvement of the parietal peritoneum. This pain and muscle spasm is located at the
right T10–T11 dermatomes (viscerosensory and visceromotor segmental reex).
In contrast, inammation that extends to involve the parietal peritoneum of the
abdominal wall in acute appendicitis activates the cerebrospinal nerve pathway.
This pathway is stimulated by movement, cough, supercial palpation, and removal
of palpatory hand or other maneuvers at a site(s) of tenderness at the parietal perito-
neum on the abdominal wall. It involves afferent pain signals transmitted through
intercostal nerves to the dorsal root ganglion and cortical pathways, and efferent
pathways stimulating alpha-motor neurons in the anterior rami with the signal trans-
mitted to the same intercostal nerves on the anterior abdominal wall causing abdom-
inal muscle spasms and guarding (somatomotor segmental reex). These somatic
segmental reexes localize the pain and spasms to the same area at the inamed
peritoneum, usually at the T10–T12 dermatomes. In general, there is a point on this
dermatomal segment involving the anterior abdominal wall, representing the site of
greatest pain rst recognized by Charles McBurney (1845–1913) in 1889 and col-
loquially known as McBurney point. The point is between an inch and a half and
2in. to the right anterior superior iliac spine on a straight line drawn from that pro-
cess to the umbilicus. What is not widely recognized by many clinicians is that this
point represents the location on the anterior abdominal wall where the parietal peri-
toneum is reexively irritated by appendiceal inammation and not the location of
the appendix. Hence, in cases where the appendix is retrocecally located in the
pelvis or involving the posterior abdominal wall, pain is less likely to be found at
McBurney point. Nevertheless, when there is supercial palpatory tenderness at
McBurney point, a clinician can be reasonably sure that the disease represents acute
appendicitis.
The sequence of events leading to activation of reexes during the acute and
chronic stages of appendicitis can be summarized as follows: In early acute appen-
dicitis, the disease is conned to the appendix or periappendiceal region, a viscero-
sensory reex is present, causing a centralized visceral pain perceived at the T8–T10
dermatomes. In some cases, when the disease is of rapid onset and severe, there may
be a “spill-over” effect into somatic segments (visceromotor and/or viscerosensory
segmental reexes) at the right T10–T11 dermatome. In the later stages of acute
appendicitis, the parietal peritoneum may be involved caused by perforation and
extension of the inammatory process to the anterior abdominal wall, such that
somatic (somatosensory and somatomotor segmental reexes) segmental pain path-
ways at the right T10–T12 dermatome or other regions of the abdominal wall are
now involved. In chronic appendicitis, the disease is again primarily conned to the
appendix. As such, only visceral pain pathways are involved, which can be central-
ized or located in the right lower quadrant, similar to what occurs in acute
appendicitis.
Understanding how these maneuvers are performed and the disease is expressed
assists clinicians with the means to determine the presence or absence of
5 Appendicitis: Somatic andVisceral Nerve Reexes Signs: Mechanisms…
129
appendicitis, knowledge of the pathophysiologic process, and the location of the
pain. Teaching the pathophysiologic process while the sign is being taught and per-
formed provides the learner with a more fundamental and in-depth appreciation of
the physical examination’s role in enumerating the disease process and establishing
a diagnosis.
This chapter reviews the abdominal signs of acute and chronic appendicitis
involved in the activation of somatic and visceral pathways and their accompanying
symptoms. In the subsequent chapter discussed are other signs named in the absence
of activation of nerve pathways. We present the signs as originally described to
avoid misrepresenting that enumerated by the primary authors. The signs are
grouped using a pathophysiologic approach and listed chronologically based on the
year they were rst reported.
5.2 Historical Background
The disease acute appendicitis has been contentious since its presumed original
description by Jean François Fernel (1497–1558) in 1554 [2]. For over three centu-
ries, there has been the absence of a unied consensus among physicians regarding
the source, diagnostic features, and treatment of this disease. It was Reginald Heber
Fitz (1843–1913) who, in 1886, established a comprehensive description of the dis-
ease in his landmark presentation and publication in 257 patients, titled Perforating
Inammation of the Vermiform Appendix: With Special Reference to its Early
Diagnosis and Treatment [3]. Fitz was the rst to coin the term “appendicitis” and
distinguish it from inammatory processes involving the cecum or pericecal regions
(typhlitis, perityphlitis, perityphlitis abscess). Fitz stated that “the term appendicitis
was preferred to typhlitis, as avoiding the possibility of a misunderstanding, and as
localizing the disease in its usual place of origin.” [3, p.13]. He further established,
elaborated on, and described the clinical features, diagnosis, course, macroscopic
pathological features, and treatment of this disease. We provide excerpts from his
time-honored description of appendicitis and appendiceal perforation, given its sig-
nicance and clarity of presentation to the history of appendicitis:
It was found that the disease occurred most frequently among previously healthy youths
and young adults, especially males; that a fecal concretion or foreign body was present as a
local cause in more than three-fths of the cases. Attacks of indigestion and acts of vio-
lence, especially when indirect, were exciting causes in one-fth of the cases. The action of
these causes was favored by a constipated habit, or by congenital or acquired irregularities
in the position and attachment of the appendix. The rst characteristic symptom of a perfo-
rating appendicitis was found to be a sudden, severe, abdominal pain. This occurred in 84%
of the cases and usually in the right iliac fossa, where tenderness could always be found,
even when the pain was referred to some other locality. (…) Fever was the next character-
istic symptom and occurred in the course of 24hours. Finally came the swelling which
made its appearance in the course of three days. The chief source of danger from the appen-
dicular peritonitis arose from its becoming generalized. Such a result followed most fre-
quently between the second and fourth days. (…) If it became evident that general peritonitis
5.2 Historical Background
130
was imminent at the end of 24hours after the sudden intense pain the appendix should be
exposed and removed. (…) More favorable results in the future were to follow the earliest
possible opening of the swelling. This in most instances was at the outset, a sac formed by
circumscribed peritonitis. It was usually present on the third day of the disease, dating from
the pain, its rst marked characteristic symptom [3, p.13].
Hence, his work was immeasurable in providing the rst unied conceptualization
of the disease and its prompt surgical treatment, thus challenging prevailing think-
ing about the disease up to that time.
5.3 Somatic Segmental Nerve Pathway Signs
There are various maneuvers, as elucidated through signs, in which somatic pain
caused by irritation of the parietal peritoneum is elicited by patient movement,
cough, supercial palpation, and other techniques, including pinching, twisting, or
releasing the depressed palpatory hand on the anterior abdomen wall (somatosen-
sory segmental reex). Other signs require the contraction of the abdominal mus-
cles (somatomotor segmental reex). In addition to the eponymously named signs
included in this review, two recent maneuvers are worth mentioning. Tzortzopoulou
etal. described the jumping up (j-up) test in children with suspected acute appendi-
citis, which involves asking the patient to “jump and try to reach both rising hands
a toy hanging down from the ceiling of the examination room” [4, p.1]. Pain in this
study was assessed by comparing the child’s facial expression to the Bier pain scale.
In another study, Eid and Al-Kaisy asked patients with suspected acute appendicitis
whether they experienced increased abdominal pain while traveling over a “speed
(trafc control) bump” or “Holly hump” [5]. Both studies reported high sensitivity
(87%, 90.5%) with lower specicity (70%, 40%) for the J-up and speed bump,
respectively [4, 5]. It should be noted that neither of these studies assessed the loca-
tion of the pain. The high sensitivity suggests that this test and sign correctly iden-
tify patients with peritonitis. The lower specicity is consistent with other conditions
occurring intra-abdominally that causes peritonitis.
5.4 Eponymous Signs
5.4.1 McBurney Sign (Point)
Charles Heber McBurney (1845–1913) was born in Roxbury, Massachusetts, USA,
and received his medical degree from the College of Physicians and Surgeons
(renamed Columbia University in 1912, and Columbia University Roy and Diana
Vagelos College of Physicians and Surgeons in 2017), NewYork in 1870 [6, 7]. He
completed his internship at Bellevue Hospital in NewYork City and received his
postgraduate training in Vienna, Paris, and London [7]. He returned in 1873 to the
5 Appendicitis: Somatic andVisceral Nerve Reexes Signs: Mechanisms…
131
College of Physicians and Surgeons with an appointment as an assistant demonstra-
tor in anatomy. He was appointed assistant surgeon at Bellevue in 1880 and sur-
geon-in-chief at Roosevelt Hospital, NewYork City, in 1888. From 1889 to 1894,
he was appointed professor of surgery, followed by a position as professor of clini-
cal surgery until 1907, after which he was bestowed the title of professor emeritus
of surgery at the College of Physicians and Surgeons [7]. McBurney was a fellow of
the American Medical Society, an honorary fellow of the Royal College of Surgeons,
Edinburgh, in 1905, and a member of the NewYork Academy of Medicine and
Surgical Society of Paris, among others [8].
In addition to the eponym “McBurney point/sign,” he is also recognized for his
contribution to the use of rubber gloves during surgery asepsis, pyloric stenosis, a
method for reducing dislocation of the humerus as a complication of a fracture at or
near the surgical neck, extraction of a common bile duct stone through an incision
in the duodenum and ampulla, inguinal hernia repair, and the operative incision in
patients with acute appendicitis (McBurney incision) [9–14]. This technique
involves splitting rather than cutting the external and internal oblique muscle bun-
dles, aponeurosis, and transversalis muscle to expose the appendix in patients with
non-perforated appendicitis [12].
Regarding his character:
As a teacher and lecturer, McBurney was simple, clear, and eminently practical. (…) In his
relations with the house staff of the hospital he was always absolute master. (…) To his
patients he was gentle, self-sacricing, sparing himself not at all. His manner was always
charming, and I have never seen a sweeter smile on any human face than he did show. He
inspired absolute condence in those under his care. His winning manner, absolute devo-
tion to duty, and superior intelligence aroused in those who worked with him professionally
the highest admiration, affection, and esteem [15, p.979].
At the NewYork Surgical Society in 1889, he presented the sign describing the
location of appendiceal pain at the right lower abdominal quadrant: “The seat of
greatest pain, determined by the pressure of one nger, has been very exactly
between an inch and half and two inches from the anterior spinous process of the
ilium on a straight line drawn from that process to the umbilicus.” [16, p. 678]
(Table5.1) (Fig.5.1).
It is of interest that Ludwig Traube (1818–1876) described in 1871 the case of a
32-year-old man, “It began initially with moderate pain, which rst appeared in the
lower half of the abdomen between the middle of the anterior superior spine and
umbilicus that continued to increase in intensity until it became more severe by late
noon yesterday” [17, p.55]. Two days later, he wrote that the “Abdomen is very
distended, tense, and sensitive to pressure everywhere but especially to the right at
the point mentioned above the iliac spine and umbilicus” [17, p.56].
The most common nding in patients with acute appendicitis is local tenderness
which initially may be masked by more generalized pain. The point of maximum
tenderness at McBurney point is xed. It thus represents not the position of the
appendix but the site on the anterior abdominal wall where the T10 and T12 sensory
afferent nerves are most commonly irritated by parietal peritoneal appendiceal
5.4 Eponymous Signs
132
Fig. 5.1 McBurney sign (by Ryan Yale)
inammation. This nding may be absent in patients with a thickened abdominal
wall or omental fat or whose appendix is located retrocecally in the pelvis or the
fossa on the posterior abdominal wall [18]. Other sites of cutaneous tenderness on
the anterior abdominal wall may also be involved, as described by Cope, Lanz,
Clado, and Gray [18]. In general, pain over McBurney point provides surgeons
reasonable condence that the appendix is more likely to be involved [18]. Hence,
even today, surgeons routinely search for this physical sign in patients presenting
with acute or subacute abdominal pain.
During the initial clinical examination in patients with acute appendicitis, Soda
etal. reported a sensitivity of 83% and specicity of 45% at McBurney point. The
positive predictive value was 76%, and the negative predictive value was 56% [19].
A meta-analysis reported a positive likelihood ratio of 1.29 (range of 1.06–1.57) and
a negative likelihood ratio of 0.25 (range 0.12–0.53) for McBurney point in acute
appendicitis [20]. Results from these studies should be interpreted with caution and
examined based on their clinical context.
5.4.2 Perman Sign
Emil Samuel Perman (1856–1946) was born in Östersund, Sweden, and received
his medical licensure in 1887 and medical degree in 1889 from the Karolinska
Institute, Solna, Sweden [21, 22]. He served as an assistant surgeon at Sabbatsberg
Hospital in Stockholm from 1886 to 1891, associate professor of surgery at
Karolinska Institute from 1891 to 1896, and chief physician at Crown Princess
5 Appendicitis: Somatic andVisceral Nerve Reexes Signs: Mechanisms…
133
Lovisa’s Care Institution for Sick Children in Stockholm from 1892 to 1899 [21,
22]. Perman was appointed chief physician in the surgical department of Sabbatsberg
Hospital, Stockholm, from 1899 to 1919 [22]. He described two methods for diag-
nosing acute appendicitis in 1904:
A symptom, the signicance which was rst pointed out by Dieulafoy (abdominal guard-
ing), which is of great importance and one that I have always found to be accurate when
present, involves muscle tension over the cecal tract and adjacent portion of the abdomen
when touched or lightly pressed. If this symptom is found, you can be almost certain that
there are already many changes in and around the appendix-free or limited gangrene or
perforation with incipient purulent peritonitis. Additionally, I found another symptom: pain
localized to the ileocecal area when pressure is applied to the left side of the abdomen [23,
p.806].
These ndings are consistent with the activation of somatomotor segmental reexes
with supercial palpation in the right lower abdominal quadrant. A somatosensory
or viscerosensory segmental nerve reex occurs when pressure is applied to the left
side of the abdomen (see Sect. 5.6.6) (Table5.1). We are unaware of any study that
evaluated the sensitivity or specicity of this sign.
5.4.3 Blumberg-Shchetkin Sign
5.4.3.1 Moritz Blumberg
Jacob Moritz Blumberg (1873–1955) was born in Posen, province of Silesia, Prussia
(currently Poland), and received his medical degree from the University of Breslau,
Wroclaw (now University of Wroclaw, Poland) in 1897 [24]. During World War I,
he served in the German army and was instrumental in devising a rapid method for
delousing the Russian prisoners of war and hence successfully contained and pre-
vented a typhus epidemic on the eastern front. This accomplishment was later
described as “one of the greatest achievements in military medical history” [24]. He
left Berlin during World War II and practiced in London, England, with his son
Ernst Friedrich Blumberg (1908–1973), who also specialized in surgery, gynecol-
ogy, and radiology [24].
In addition to the sign which bears his name, Moritz Blumberg’s other notable
surgical accomplishments included redesigning the rubber surgical glove (Blumberg
glove), designing an instrument to facilitate suturing of the perineum, describing the
buttonhole incision, and developing a procedure for temporary sterility in women
[24]. His character was described as a “sympathetic, yet rm personality having
inspired immediate condence in those who sought his advice” [24].
Blumberg described in 1907 a method for determining whether the parietal peri-
toneum is irritated by an inamed appendix (Fig.5.2):
Very different results occur when pressure is applied compared to when the palpating hand
is raised. In my opinion, it is always necessary to consider these two movements separately
based on the type of pain they induce. For example, rst, apply pressure on the area of the
5.4 Eponymous Signs
134
abdomen to be examined and ask the patient whether it is painful. After listening to the
response, suddenly lift the palpating hand and ask the patient whether it was painful when
the hand was removed and which of the two types of pain was greatest. (…) I noted an
extremely violent pain, causing the patient to momentarily grimace, when the palpating
hand was suddenly lifted. During an acute episode the patient stated with certainty that the
pain was greatest when the hand was suddenly lifted compared to when it was pressed. In
cases of less severe inammation involving the peritoneum, the pain when the hand was
suddenly lifted was similar to when the hand was pressed. As the healing process pro-
gressed, the pain was less when the hand was lifted and nally remained only vaguely
present, presumably caused by adhesion, when the hand was lifted. The pain completely
disappeared when chronic disease was present [25, p. 1177]. (…) The method can be
applied accurately since it is not a matter of assessing the extent of the pain but comparing
the intensity of the two pains. This information is reliably conveyed by the patient [25,
p.1178].
Blumberg recognized the peritoneal origin of the pain and that it was present in
cases of acute appendicitis and other inammatory processes involving the perito-
neum [25]. He concluded that this nding suggests a serious underlying intra-
abdominal process if it occurs suddenly after disease onset. At the same time, its
gradual decrease in intensity provides reassurance of the resolving underlying peri-
toneal process [25] (Table5.1).
Fig. 5.2 Blumberg (Shchetkin) sign (by Ryan Yale)
5 Appendicitis: Somatic andVisceral Nerve Reexes Signs: Mechanisms…
135
5.4.3.2 Dmitri Shchetkin
Dmitri Sergeevich Shchetkin (1851–1923) was born in Ryazan, Russia, and received
his medical degree from St. Petersburg Medical and Surgical Academy in 1877
[26]. He was an intern during the Russo-Turkish war (1877–1878) and completed a
one-year internship at the Clinical Military Hospital in St. Petersburg, where the
focus of his studies was directed toward obstetrics and gynecological surgery [26,
27]. Here he successfully passed the doctorate in medicine certication examination
and doctoral dissertation, delivered at the St. Petersburg Medical and Surgical
Academy, titled “On Conditions Predisposing to the Development of Venous
Thrombosis after Ovariectomy.” [26]. Shchetkin served as vice-president of the
Ryazan Medical Society from 1884 to 1888, a senior (chief) physician at the Ryazan
Provincial Zemstvo Hospital from 1888 to 1902, and a senior physician at the Penza
Provincial Zemstvo Hospital from 1902 to 1917 [26, 27].
Shchetkin and other gynecologists and surgeons practicing at Ryazan, Russian
Empire in the late 1880s, and Penza Provincial Zemstvo I Hospital, the Soviet
Union in 1902, were reportedly performing this sign before Blumberg’s 1907 pub-
lication [26–29]. Shchetkin reported at the Penza Medical Society in 1908 the fol-
lowing sign found in patients with peritonitis:
The symptom is that if you put your hand over the patient’s abdomen and lightly press, pain
in the abdomen is usually not felt. The patient feels severe pain soon after the examiner lifts
his hand from the abdominal wall. The symptom is particularly characteristic in cases of
local peritonitis because it accurately indicates the location of the disease on the perito-
neum. It also serves as a valuable sign for general peritonitis. In addition to this, it is an
important nding in the differential diagnosis of peritonitis and abdominal wall pain simu-
lating peritonitis [27, p.51].
In his paper “On the abdominal tremor,” Shchetkin described another palpatory
nding in patients with intestinal adhesions; a vibratory sensation transmitted to the
abdominal wall while talking in patients with intra-abdominal adhesions extending
between the intestines and the abdominal wall [28].
Several studies have evaluated the Blumberg-Shchetkin sign in patients with
acute appendicitis. Andersson (2004) reported a positive and negative likelihood
ratio of 1.99 and 0.39, respectively [20]. In a study of 100 patients presenting with
right iliac fossa pain, Golledge etal. (1996) reported a sensitivity and specicity of
82% and 89%, respectively, with a positive predictive value of 86% [30].
Additionally, in a large case series, a sensitivity ranging from 40 to 95%, specicity
20 to 89%, and positive and negative likelihood ratios of 2.1 and 0.5 were found
[31]. Recall that the sign demonstrates the presence of rebound tenderness caused
by irritation of the parietal peritoneum. Thus, a moderately high suspicion of the
disease suggests that the patient is likely to have peritonitis if the test is positive.
Conversely, the low likelihood ratio is consistent with a lower risk of peritonitis in
a patient with a negative test.
5.4 Eponymous Signs
136
5.4.4 Illoway Sign
Henry Illoway (Illovy) (1847–1932) was born in Kolin, Bohemia, and received his
medical degree from Miami Medical College of Cincinnati, Ohio, in 1869 [32–37].
He completed his residency training at Cincinnati Hospital from 1869 to 1870 and
was a private practitioner and later a visiting physician at the Jewish Hospital,
Cincinnati [32, 33, 35, 37].
Illoway was appointed professor of diseases of children at Cincinnati College of
Medicine and Surgery in 1888 [35, 37]. He studied in Berlin under the tutelage of
Ismar Isidor Boas (1858–1938) and Emanuel Mendel (1839–1907) and in Vienna
with Leopold (Löb) Oser (1839–1910). He then returned to the USA to treat gastro-
intestinal diseases and serve the poor in NewYork City beginning in 1894 [34, 35,
37]. He was a fellow of the NewYork Academy of Medicine and a member of the
NewYork County Medical Society, Society of Medical Jurisprudence, and German
Medical Society, among others [33, 36].
Illoway described a maneuver for diagnosing appendicitis (Table5.1) (Fig.5.3):
The patient is placed at full length upon the operating table or chair for the purposes of
examination. This is made in the usual way, and when all the data have been obtained, I tell
him or her: (a) to ex the leg upon the thigh and the thigh upon the trunk. I now ask if the
movement, or rather the upward pressure thus made, causes any pain or soreness in the
lower portion of the right half of the abdomen, i.e., the appendicular region. If the answer is
“no” or “very little,” either I myself, ex (b) the thigh more closely, more forcibly upon the
trunk or direct the patient to do so. Again, I inquire, does it cause pain or soreness, or does
it increase the pain or soreness? I now have the patient, (c) extend the leg to full length with
a quick and rather sudden movement, and ask whether this has caused any pain or soreness.
If neither of these movements has caused any appreciable pain or soreness, I direct the
patient to execute the same movements with the left leg, and to compare the sensation pro-
duced, as to whether it is any different from that caused by the right leg, or whether it is the
same on both sides. (…) It is the pain or even soreness produced both on exion and
extension—and I lay the greater stress on the extension—that I regard as a positive and
unfailing sign of the presence of appendicitis [38, p.252–253].
Pain felt on the right iliac fossa suggests inammatory involvement of the more prox-
imal portion of the psoas muscle or an area adjacent to the psoas muscle (iliopsoas).
We are unaware of any study that evaluated the sensitivity or specicity of this sign.
5.4.5 Caden Sign
James Albert Corscaden (1881–1964) was born in Providence, Rhode Island, USA,
and received his medical degree from the College of Physicians and Surgeons
(renamed Columbia University in 1912), NewYork, in 1906 [39]. He completed an
internship at Presbyterian Hospital, NewYork, in 1907 and was a private practitioner
at the time of the publication with Ellsworth Eliot, Jr. (1864–1945) of their manu-
script titled “Intussusception with Special Reference to Adults” in 1911 [39, 40].
Ellsworth Eliot, Jr. was a surgeon, and Corscaden served as an assistant surgeon
in the outpatient department at Presbyterian Hospital [40]. Corscaden was appointed
5 Appendicitis: Somatic andVisceral Nerve Reexes Signs: Mechanisms…