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137
Fig. 5.3 Illoway sign (by Ryan Yale)
5.4 Eponymous Signs
138
to the College of Physicians and Surgeons faculty in 1938. He held an appointment
in the Department of Obstetrics and Clinical Gynecology at the College of Physicians
and Surgeons, where he remained throughout his career [39].
Eliot and Corscaden described the ndings that distinguish acute appendicitis
from intussusception:
A correct diagnosis is usually possible by noting that the tumor associated with appendicitis
is almost invariably xed and enjoys little if any respiratory movement. Moreover, the asso-
ciated muscular rigidity is of great importance. In appendicitis it is almost always most
marked in the lower right quadrant, while in intussusception the symptom, if present, is
generally more marked on one side or the other of the umbilicus, while the intervening
abdomen between this area and either inguinal region is either less rigid or entirely free
from any rigidity whatever [40, p.184].
Thus, Caden or Corscaden sign refers to muscular rigidity in the lower right abdom-
inal quadrant (somatomotor and/or visceromotor reex) (Table 5.1). It is unclear
why any attribution for this sign was not credited to Eliot. We are unaware of any
study that evaluated the sensitivity or specicity of this sign.
5.4.6 Chutro Sign
Pedro (Piedro) Chutro (Cortajerena) (1880–1937) was born in Chascomús, province
of Buenos Aires, Argentina, and received his medical degree at the Faculty of
Medicine, University of Buenos Aires in 1904 [41]. His doctoral thesis was titled
“Fracturas de la Extremidad Inferior del Húmero en los Niños” (Fractures of the
Lower Extremities of the Humerus in Children) [42, 43]. During his medical training,
he worked in the Children’s Surgical Service at the Hospital de Clinicas under the
aegis of Alejandro Posada (1870–1902) and Marcelino Herrera Vegas (1870–1958)
[43]. He continued his studies in Vienna, Berlin, and Paris and, upon his return,
served as head of the surgical service in 1908 and a substitute professor of operative
medicine at Teodoro Álvarez Hospital in 1909 and the surgical clinic in 1914 [41, 43].
During World War I, he was appointed rst assistant at Lycée Buffon Hospital, Paris,
in 1915, rising to the rank of commander of the surgery services [41, 43, 44]. Here he
successfully treated osteomyelitis and bone sinuses caused by wounds. For his work, he
received the Distinguished Service Medal from the USA and the Knight of the Legion
of Honor from France [43, 45]. Upon his return to Buenos Aires, Chutro served as full
professor of the surgical clinic at Durand Hospital, followed by an appointment as titu-
lar professor and chair of clinical surgery at Ramos Mejía Hospital in 1919 [41, 44].
Among his other accomplishments, he was a founding member of the Society of
Surgery of Buenos Aires in 1911, a member of the Academy of Medicine in Paris and
the National Society of Surgery from 1916, and a foreign correspondent for the division
of surgery in the National Academy of Medicine from 1920 to 1937 [44]. He identied
the method of adding sodium citrate to blood to prevent its coagulation in 1914 [46].
A description of his character by Domingo Prat:
As a physician, he was rigid, stern, and a zealous guardian of the precious health of the sick,
which society entrusted to his care. He believed in the need for a harmonious existence and
5 Appendicitis: Somatic andVisceral Nerve Reexes Signs: Mechanisms…
139
respect for the pain of his fellow men. He prevented it not because that took away the bril-
liance of his operations, but because of his love for his neighbor and his deep respect for the
hospitalized patient. This part of his personality constituted a model of discipline and order,
which morally and technically constituted an exemplary role model for early physicians.
For this reason, his surgical clinic service stood out for its exemplary operation and disci-
pline. This great teacher, who just disappeared from the surgical stage from Río de la Plata,
constitutes an extraordinary and irreplaceable loss for Argentine surgery and Río de la Plata
[47, p.114, 116].
Pedro Chutro described a nding observed in patients with acute appendicitis:
For a long time, I have been struck by the frequent occurrence of the deviation of the
abdominal midline to the right. This type of appendicular sign can be easily observed
because the pigmentation almost always follows the tracing of the midline. The deviation
follows a curved shape, with a more or less pronounced arch, convex to the right and whose
most protruding point is at the level of the navel. The explanation of this phenomenon is
straightforward; pathophysiology teaches us that when the peritoneum is inamed, the
broad muscle, especially the transversus, goes into permanent contraction and moves the
linea alba to the right, with the skin accompanying the muscle plane. The navel plays an
important role. Frequently it is difcult to conrm the tracing of the midline. When extend-
ing a thread from the xiphoid process to the middle of the pubic symphysis, it is observed
that the entire navel is placed to the right of said line as if it had moved laterally [48, p.4].
(…) This sign is important concerning the disease’s progress since the navel’s return to its
usual place and shape does not follow the disappearance of other symptoms; it returns
slowly [48, p.5].
Chutro found that inammation of the parietal peritoneum causes abdominal wall
contraction (somatomotor reex) and deviation of the umbilicus to the right
(Table5.1). We are unaware of any study that evaluated the sensitivity or specicity
of this sign.
5.4.7 ten Horn Sign
Carel Hendrik Leo Herman ten Horn (1884–1964) was born in Veendam, Groningen,
The Netherlands. He served as a voluntary assistant, followed by a rst assistant in
the surgical clinic at the University of Amsterdam from 1908 to 1914 [49]. He was
the director of the surgical and urological departments at the Den Helder Naval
Hospital, The Netherlands, from 1914 to 1915. His academic appointments included
a professor by special appointment (extraordinary professor) in 1916, a full profes-
sor from 1916 to 1918, and a director of the Department of Surgery of the Faculty
of Medicine and Health Sciences, Ghent University, Belgium, from 1917 to
1918 [49].
He described the method and expected ndings in patients with acute appendici-
tis after applying traction on the right spermatic cord (Fig.5.4):
During the examination, one must avoid any unnecessary pressure on the testis. Grasp the
spermatic cord between the thumb and index nger above the testis. Gentle pulling of the
spermatic cord produces a displacement of the parietal peritoneum near the inner inguinal
ring. It is well known that the slightest pull is painful when the peritoneum is inamed [50,
p.1537].
5.4 Eponymous Signs
140
Fig. 5.4 ten Horn sign (by Ryan Yale)
ten Horn found that twelve patients with acute appendicitis reported pain in the right
iliac fossa after downward traction on the right spermatic cord. In some cases, he also
noted that traction on the left spermatic cord was also painful. In these cases, abun-
dant serobrinous exudate was found intraoperatively within the abdominal activity
[50]. Thus, traction of the right spermatic is believed to cause pain in the right iliac
fossa due to the apposition of the gonadal vessel and connective tissue against the
inamed parietal peritoneum in cases of perforated appendicitis (Table5.1). We are
unaware of any studies that assessed the sensitivity and specicity of this sign.
5.4.8 Lanz Sign
Otto Lanz (1865–1935) was born in Stefsburg, Thun district, Canton of Bern,
Switzerland, studied medicine at the Universities of Geneva, Bern, Basle, and
Leipzig, and received his medical degree from the University of Bern in 1891 [51].
He became an associate professor in surgery in 1893 and a surgical assistant at the
University Clinic under Theodor Kocher (1841–1917) from 1890 to 1897 [51].
Lanz was a private practitioner in Lindenhofspital, Switzerland, and a full professor
of surgery at the University of Amsterdam in 1902 [51]. He was an avid art collector
who possessed a collection of paintings from the fourteenth through the sixteenth
centuries. Part of the collection was displaced at the Rijksmuseum in Amsterdam in
5 Appendicitis: Somatic andVisceral Nerve Reexes Signs: Mechanisms…
141
1935, forcefully acquired in 1941, and later returned after the war [51]. In addition
to the sign of appendicitis, which bears his name, Lanz also contributed to asepsis,
thyroid surgery, and mesh split-skin graft [51, 52].
As to a description of his character:
If he sometimes outwardly seemed a little stern, anyone who had once felt the warm look
in his eyes knew that he was facing a sympathetic, understanding man and, at that moment,
regarded him more as a fatherly friend than a scholar. And how many consulted him for
other than physical suffering. His concern for the patients entrusted to him knew no bounds.
When a patient was in danger of life, he did not depart from the sickbed, accustomed to
every means that might still help, and many a person owes their life to his faithful care
where everything seemed already lost [52, p.1368].
Lanz described a nding involving the inguinal canal in patients with appendicitis
(Fig.5.5):
Based on dozens of cases of acute appendicitis examined, I have the impression that the
cremaster reex on the right side is usually weakened or absent. In addition, in acute cases,
I have often found that the right spermatic cord is thickened probably as a result of collat-
eral edema, and exquisitely sensitive to pressure when it is rolled back and forth with the
ngers when examined at the exit from the anterior inguinal ring, at the medial attachment
of the Poupart ligament, just lateral to the pubic tubercle. For years I have also repeatedly
taken the opportunity to use the muscular defense to follow a nger inserted into the ingui-
nal canal. At the same time, one occasionally feels a degree of tension in the anterior canal
wall, which is quite striking compared to the left side. One can easily and painlessly insert
the ngertip or entire index nger into the inguinal canal on the left. The intensely stretched
inferior border of the inferior oblique and transversus muscle on the right side prevents
penetration of the nger into the inguinal canal. Trying to perform the same maneuver on
the right side is painful, while it is not painful on the left side. The patients complain of pain
on coughing when the nger is inserted [53, p.1705–1706].
Fig. 5.5 Lanz sign (by Ryan Yale)
5.4 Eponymous Signs
142
Lanz described the absent or diminished right cremasteric reex, thickened and
tender right spermatic cord, and tension involving the right anterior wall of the
inguinal canal in males with acute appendicitis (Table5.1). We are unaware of any
studies that assessed this sign’s sensitivity and specicity.
5.4.9 Morris Sign
Robert Tuttle Morris (1857–1945) was born in Seymour, Connecticut, USA, and
received his medical degree from the College of Physicians and Surgeons (renamed
Columbia University in 1912), NewYork, in 1882 [54, 55]. He was an assistant house
surgeon at Bellevue Hospital from 1882 to 1884 and subsequently traveled abroad to
Europe for additional training in surgery [54]. He was on staff as an instructor in
surgery at the faculty of Post Graduate Medical School, NewYork, in 1889 and chair
and attending surgeon from 1898 to 1917 [55]. Morris was an associate editor of the
New England Medical Monthly and Journal of the Linnean Society of Natural History
[54]. He was elected president of the American Therapeutic Association in 1916 [55].
As to his character:
Doctor Morris was always an interesting and impressive gure in the surgical clinic. His chief
purpose was to arouse the attention of his students, to stimulate them to think. His case presen-
tations were rarely logical expositions but rather entertaining and dramatic, interlarded with an
abundance of surgical aphorisms. He used irony to arouse attention and had a sly and subtle
wit. Sarcasm was not in his speech and he was always a worthy opponent in medical debate.
Doctor Morris possessed in a singular degree serenity, urbanity, dignity, and restless curiosity
of mind. He was a uent lecturer on widely diverse subjects; his spirit and his mind were
attuned to the rapid evolution not only of medicine but also the cognate sciences [55, p.958].
Morris described two ndings to assist in the diagnosis of chronic appendicitis. The
rst involved a point of tenderness on the anterior abdominal wall:
[t]he greatest degree of tenderness on pressure is at the point a half inch to the right of the
navel, close to the spinal column, and corresponding to the right sympathetic lumbar gan-
glion [56, p.2036].
This point of tenderness was absent in acute cases of appendicitis, and if it occurs in
pelvic irritations or infection, it is present bilaterally (Table5.1). The other nding
was referred to as the “cider barrel sign” a term used to describe the percussion
sound on the right side of the abdomen in patients with chronic appendicitis.
5.4.10 Cope Signs
Sir Vincent Zachary Cope (1881–1974) was born in Hull, Kingston-upon-Hull, England,
and conferred his medical degree with honors from St. Mary’s Hospital Medical School,
London [57]. He remained at St. Mary’s Hospital throughout his career, practicing sur-
gery and maintaining a zest and passion for medical history [57, 58]. He joined the
medical corps in 1914 and served in World War I from 1916 to 1919 [57]. His rst book,
5 Appendicitis: Somatic andVisceral Nerve Reexes Signs: Mechanisms…
143
Surgical Aspects of Dysentery Including Liver-Abscess, published in 1920, described
his and his colleagues’ experiences with the surgical management of dysentery during
the war [57]. He authored the time-honored book, The Early Diagnosis of the Acute
Abdomen in 1921, with revisions extending to the fourteenth edition [58, 59].
In the Royal College of Surgeons, he was a court of examiners and council mem-
ber and chairman of the committee to the Ministry of Health, responsible for sur-
veying hospital facilities, workforce, and training from 1949 to 1952 [57, 58]. He
compiled under the direction of an Inter-Services Editorial Board the volumes
Medicine and Pathology in 1952 and Surgery in 1953 of the History of the Second
World War [58]. In recognition of these works, he was bestowed knighthood in 1953
[58]. Cope wrote other historical books, essays, and biographies that are too numer-
ous to enumerate in this brief biographical sketch. Many societies recognized and
honored his distinguished career, including the Royal College of Surgeons, the
Medical Society of London, and the Royal Society of Medicine [58]. In the words
of William Richard Lefanu (1904–1995):
In private life he was the most equable, modest, and friendly of men. (…) He often said that
the good surgeon must feel for his patients, but never let this sympathy disturb his judgment
or treatment; he had the strength to obey this counsel of perfection in his own case [58, p.308].
Three signs have been named for Cope, with two, psoas and obturator, used to diag-
nose appendicitis. The third, a misnomer, is incorrectly named in the literature in
patients with cholecystitis. O’Reilly and Krauthamer coined the term “Cope sign”
to describe their nding of two patients with acute cholecystitis and bradycardia
[60]. Cope, however, in his paper “A sign of gall-bladder disease,” reported:
For six months before my recent illness, I occasionally had attacks of profuse sweating and
increased pulse rate that woke me from sleep, but usually passed off within half an hour.
They were not accompanied by any pain. A physician found my heart normal. (…) I do not
know whether the nocturnal bout of sweating and rise in pulse rate had any connexon with
the presence of gall stones, but it may be signicance that since the operation a year ago I
have not had a similar attack [61, p.147–148].
Cope’s symptoms of increased heart rate caused by biliary colic and chronic calcu-
lous cholecystitis were consistent with the activation of alpha-adrenergic sympa-
thetic pathways [62]. The phenomenon that O’Reilly and Krauthamer (1971)
reported was a cardio-biliary reex, a group of disorders involving afferent and
efferent nerve pathways that inappropriately lead to vasodilation, bradycardia, hypo-
tension, and syncope [60]. The afferent pathway for this reex originates in the
gallbladder, is vagally mediated, and activated in response to mechanical stimulation
resulting in bradyarrhythmia (e.g., atrioventricular block, high grade, or complete
heart block) and other symptoms secondary to heightened parasympathetic tone [63].
Cope described two maneuvers in the diagnosis of acute appendicitis. The rst
was reported in 1921 and referred to as the iliopsoas rigidity (psoas extension test)
(Table5.1) (Fig.5.6):
It is well known that if there is an inamed focus in relation to the psoas muscle the corre-
sponding thigh is often exed by the patient to relieve the pain. A lesser degree of such
contraction (and irritation) can be determined often by making the patient lie on the oppo-
site side and extending the thigh on the affected side to the full extent. Pain will be caused
by the maneuver if the psoas is rigid from either reex or direct irritation [59, p.42].
5.4 Eponymous Signs
144
Fig. 5.6 Cope (Iliopsoas) sign (by Ryan Yale)
A variation of this test that departs from Cope’s original description includes having
the patient supine and exing the thigh against the examiner’s hand placed above
the knee. In severe cases, the inammation may cause a xed exion deformity of
the hip [64]. This maneuver is most likely positive in cases of retrocecal appendici-
tis in which the inamed appendix is juxtapositioned against the psoas muscle, a
primary or secondary psoas abscess arising from the psoas, a paraspinal condition,
or a disorder involving the ureter or bladder [65]. A negative test is more likely to be
found if the anterior abdominal wall is rigid or the inammation is subacute [65–
67]. The sensitivity of the psoas sign ranges from 13 to 42%, specicity of 79–97%,
and a positive likelihood ratio of 2.0 for detecting appendicitis [63, 64]. Andersson
reported a positive likelihood ratio of 2.31 (1.36–3.91) and a negative likelihood
ratio of 0.85 (0.76–0.95) for the psoas sign in acute appendicitis [20]. Thus, a posi-
tive psoas sign increases the probability of having appendicitis, while a negative test
result only modestly decreases the likelihood of disease.
Vasilii (Vasily) Parmenovich Obraztsov’s (1849–1920) name has been associ-
ated with the psoas test. We were unable to verify his description of the test and the
year it was reported [68, 69]. In a study on 19,346 patients with acute appendicitis,
Obraztsov sign was identied in 62.1% of those with acute appendicitis and in 3.7%
of patients in which the appendix was in a retrocecal position [70]. A sliding palpa-
tory technique for deep abdominal palpation has been attributed to Obraztsov-
Strazhesko [71].
5 Appendicitis: Somatic andVisceral Nerve Reexes Signs: Mechanisms…
145
Cope, in 1919, described another method to diagnose acute appendicitis in cases
where appendiceal or other causes of pelvic inammation are located below the
pelvic brim adjacent to the lateral wall (Table5.1) (Fig.5.7):
The right thigh is slightly exed (so as to relax the psoas muscle) by the surgeon, who
stands on the right of the patient; the limb is then fully rotated at the hip, rst internally and
then externally, so as to put the obturator internus through a full range of movement. The
sign is positive if the patient complains of hypogastric pain when the limb is moved in this
manner [72, p.537].
According to Cope, the obturator test is more likely to be positive under the follow-
ing circumstances:
Since the fascia covering the obturator internus is fairly dense, the test is not positive unless
the inammation is considerable; and, with a positive result, one always expects the appen-
dix to be adherent to, or even an abscess to be contiguous to, the fascia. I have found this
sign of assistance not only in cases of appendicitis, but also in other pelvic conditions such
as rupture ectopic gestation, and I have no doubt that it will often prove of value in doubtful
cases [72, p.537].
Examples of conditions that irritate the obturator internus muscle include inamma-
tory uid in the pelvis, abscess, or perforated appendix. This test has been found to
have a low sensitivity (8%) and high specicity (94%) in diagnosing appendicitis
[67]. It should be recognized that Cope only described the location of the pain for
Fig. 5.7 Cope (Obturator) sign (by Ryan Yale)
5.4 Eponymous Signs
146
the obturator and not the psoas sign. The psoas and obturator internus muscles are
retroperitoneally located. Unlike the obturator internus, which is innervated by the
L5-S2 nerves, the psoas muscle is located within the lower abdomen and pelvis,
originates from the vertebral bodies of T12 and L1–L3, inserts in the less trochanter
of the femur, and is innervated by L1–L4 nerves. Thus, depending on the location of
the inammatory process along the course of the right psoas muscle, pain may be
perceived in the lower back, right lower quadrant, inguinal and hypogastric regions,
hip, thigh, or knee. Inammation of the obturator internus or other structures within
the pelvis innervated by lumbosacral nerves causes pain to be perceived within the
hypogastrium (suprapubic region).
Interestingly, Cope described the clinical symptoms of testicular pain occurring
in acute appendicitis in the absence of signs elicited on physical examination. The
pain may be present early in the course of the disease, occur in the right, left, or both
testicles, and last up to two days. He postulated that the pathophysiologic mecha-
nism involved the activation of sympathetic bers arising from T10 spinal cord
segment-nerves bers also innervating the appendix. This mechanism represents a
viscerosensory reex of referred pain [73]. Furthermore, he also recognized the
nding of testicular contraction on the right side in patients with acute appendicitis
which he believed to be caused by irritation of the genito-crural (genitofemoral
nerve) [73].
5.4.11 Gregory Sign
We were unable to identify any historical information on Arthur Gregory. At the
time of the publication of his sign in 1922, he served as chief physician of the surgi-
cal department of the Vologda Military Hospital, Russia [74].
Gregory described a method for diagnosing acute, subacute, and chronic appen-
dicitis. His discussion of the sign occurring in chronic appendicitis is found under
visceral segmental reexes. The somatic nerve reex sign involves:
Percussion midway between the umbilicus and anterior superior iliac spine causes tremor
of the small intestines which is transmitted unimpeded (muscle contraction is absent) to the
diseased appendix causing pain at McBurney’s point. In acute and subacute appendicitis,
the symptoms are clearly pronounced; even slight percussion causes an intense pain sensa-
tion at McBurney’s point [74].
Gregory also found another somatic and visceral nerve reex sign:
In some cases, where the appendix is located medially due to adhesions in the areas of the
small intestine, percussion between the umbilicus and the anterior superior iliac spine
causes pain not only at McBurney’s point but also at umbilicus and epigastrium. With the
appendix in a pelvic position, pain during percussion was felt in the suprapubic region [74,
p.398].
Thus, Gregory sign refers to pain occurring at McBurney pain upon percussion of
the abdomen between the umbilicus and anterior superior iliac spine or directly at
McBurney point in acute and subacute appendicitis (somatosensory nerve reex)
5 Appendicitis: Somatic andVisceral Nerve Reexes Signs: Mechanisms…