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(Table5.1). The referred nature of the pain at the umbilicus and epigastrium occurs
in cases where the appendix is located medially and is consistent with a viscerosen-
sory nerve reex. Likewise, pain in the hypogastrium is consistent with somatosen-
sory nerve reex caused by irritation of nerves within the pelvis.
5.4.12 Sattler Sign
There is limited historical information on Eugen Sattler. He was a senior surgeon in
the surgical university Clinic and St. Stefan Hospital in Pressburg (Budapest) until
1925 and in the surgical department of the polyclinic for war invalids, widows, and
orphans in Budapest in 1926 [75–78].
Sattler presented a lecture at the September 15th, 1923, Congress of the Society
of Hungarian Surgeons, where he described a maneuver for isolating the iliopsoas
muscle as a method for distinguishing appendicitis from right adnexitis:
We achieve this when the upper body is in a sitting position, and the legs are in a horizontal
position with the axis of the upper body. In this position, the origin and insertion of the
sartorius and tensor fasciae latae move closer to each other, causing their musculature to be
completely relaxed. The patient sitting on a straight bed with the legs outstretched is asked
to lift the right leg. In doing so, the patient exes the hip joint, triggering isolated iliopsoas
action. To accurately perform the examination, the legs must be extended so that the auxil-
iary muscles do not become active. Most patients tend to bend the upper body backward in
order to support the painful iliopsoas activity with the accessory muscles. Therefore, an
assistant must support the patient’s back with his hand. The patient holds his hands beside
his body but does not lean on them. When asked to do so, the patient tries to raise his leg.
In healthy people, this occurs only under a slight angle; in weak or ill patients, of course, at
an even smaller angle. Now I take hold of the patient’s right leg and bend it further, asking
him to point my nger to the painful spot in his abdomen. The point which I call the “appen-
dix point” so designated is the boundary point of the right lateral third, on a straight line
connecting the two anterior superior iliac spines (the point determined by Lanz). This point
is almost the same in all cases, regardless of the position of the four known locations the
processus vermiformis occupies. In some cases, there may be an insignicant change in the
position of this point, a little up or down [79, p.349–350].
He postulated that this maneuver causes the appendix to be compressed between the
psoas muscle and the abdominal wall. Sattler also described the location of adnexal
tenderness, which he named the adnexal point:
During further investigations, I noticed that female patients described another spot as the
painful point in adnexitis. With the help of the same examination method, the female
patients with diseases in the adnexa described a painful spot, which I called the “adnexal
point,” as a painful point. I could paraphrase this point so that it corresponds to the lower
point of an isosceles triangle, the two sides of which are the length of the outer third of the
area of a straight line connecting the two anterior superior iliac spines. The proximal limb
falls in this line, and the base of the triangle is half the length of the limb [79, p.350].
Thus, Sattler sign refers to pain located at Lanz point occurring upon exion of the
extended leg onto the abdomen. The mechanism is more likely to be accounted for
by inammation involving the iliopsoas muscle rather than compression of the
appendix between the psoas muscle and abdominal wall (Table5.1).
5.4 Eponymous Signs
148
5.4.13 Gray Sign
Sir Henry McIlree Williamson Gray (1870–1938) was born in Aberdeen, Scotland,
and received his medical degree from the University of Aberdeen Medical School,
graduating with honors in 1895. In Aberdeen, he was a private surgical practitioner
from 1896 to 1903 [80]. He served as a surgeon during the South African (Boer)
War and was invalided home with the rank of Major [81, 82]. During World War I,
he obtained the rank of colonel in the Army Medical Service in 1914, consulting
surgeon to the British Extraordinary Force in Rouen, France, and from 1917 as a
consulting surgeon to the British Third Army [81, 82]. Gray was awarded the Order
of the Bath Companion in 1916 and St. Michael and St. George Companion in 1918
[80]. He was appointed consultant of the Special Military Surgery in England until
1919. In that same year, Major (Temp. Lieut. Col.) Gray of the Royal Army Medical
Corps (Territorial Force) was annotated Knights Commander of the Military
Division of the said Most Excellent Order [83].
Gray served as consultant surgeon to the Royal Hospital for Sick Children begin-
ning in 1923 and was appointed surgeon-in-chief at the Royal Victoria Hospital and
as faculty at McGill University, Montreal, Quebec, Canada [81, 82]. The appoint-
ment of Gray at McGill University was contentious as he was not appropriately
vetted and consequently usurped through the university teaching hospital appoint-
ment protocol committee chaired by Principal Sir Arthur Currie (1875–1933) [80].
In recognition of his appointment to the Royal Victoria Hospital and McGill
University and commemorating his contributions while at Aberdeen, the following
was said about Gray:
The profession in the North of Scotland and indeed, throughout Great Britain will receive
with very mixed feelings the announcement that Sir Henry W. Gray, KBE, CB, surgeon to
the Aberdeen Royal Inrmary, has accepted the appointment of chief of the surgical staff of
the Royal Victoria Hospital, Montreal. On the one hand they will congratulate Canada on
having obtained his services, and Sir Henry Gray himself on the wide scope which the great
McGill Medical School and the splendidly appointed Victoria Hospital will offer him; but
on the other they will regret that Scotland and Aberdeen should lose a teacher of such well-
deserved popularity and a surgeon of so much originality and skill [84, p.730].
Gray resigned from his position at the Royal Victoria Hospital two years later
and became a private practitioner and head of a private hospital in Montreal, Canada
[80, 81].
Gray described a method for diagnosing submesenteric appendicitis:
If one presses with the point of a nger somewhere about 11/2″ below and to the left of the
umbilicus one can frequently elicit tenderness there. Occasionally, at the tender spot, there
seems to be a small aperture in the rectus sheath. It is possible that this tender spot corre-
sponds to the point of emergence of the terminal branch of the 11th dorsal nerve. The
amount of pressure required to produce the feeling of tenderness is estimated. The pressure
is relaxed and then with the back of the hand diffuse pressure is made and sustained over
the appendix region, which is usually also tender. Then the same amount of pressure is
exerted at the same spot as before on the left side, with the point of a nger of the other
hand. If the sign is positive the tenderness there is not now appreciated by the patient or is
lessened considerably in degree. This sign, when positive, is evidence of the presence of
5 Appendicitis: Somatic andVisceral Nerve Reexes Signs: Mechanisms…
149
either a submesenteric appendix or a Lane’s terminal ileal membrane. If the presence of a
retrocecal or retrocolic appendix has been already established, then this sign indicates a
Lane’s membrane only [85, p.36–37].
Thus, Gray sign refers to pain occurring by pressure exerted 11/2in. below and to
the right of the umbilicus in acute appendicitis. We are unaware of any study that
evaluated the sensitivity or specicity of this sign.
5.4.14 Przewalsky Sign
We could not identify any historical information on B.Przewalsky (B.Przewalski).
He served as chair in the department of the I.Military Hospital Kharkov in Ukraine
(Southern Russia) when he published his paper “Diagnostik der Appendicitis chron-
ica” (Diagnostics of Chronic Appendicitis) [86].
Przewalsky identied a nding in patients with chronic appendicitis (Fig.5.8):
The patient lies supine on a table with the legs positioned a hand width apart. The leg to be
examined lies within the heel of the examiner’s hand, a few inches above the table. The
examiner begins to count the seconds when his hands are removed. (…) Healthy people can
maintain both legs stretched above the table for about two minutes. The extended right leg
cannot remain elevated for more than 15seconds if the right iliacus muscle is atrophic and
if there is lymphadenopathy surrounding the right iliac artery [86, p.1079].
Przewalsky identied on palpation enlarged lymph nodes surrounding the right
circumex iliac artery and atr ophy of the right iliacus muscle laterally from the
external iliac artery resulting from the inammatory process in adult patients with
chronic appendicitis. These ndings accounted for the functional weakness in
exion of the right leg [86, p.1078]. We are unaware of any study that evaluated
the sensitivity or specicity of this sign. Przewalsky described another nding
involving air within the rectal ampulla in patients with acute appendicitis (see
Chap. 6).
5.4.15 Gray (Shoulder) Sign
Irving Gray (1892–1953) was born in NewYork City, USA, received his medical
training at NewYork University and in the Medical College of Bellevue Hospital,
and received his medical degree from the latter in 1913 [87, 88]. He was an intern at
the Jewish Hospital, Brooklyn, NewYork City, from 1913 to 1915, was the recipient
of the Glover C.Arnold Surgical Prize in 1914 and entered general practice in 1915
[87, 89].
He was an associate in medicine and chief of the gastro-enterologic clinic at the
Jewish Hospital, Brooklyn, and a gastroenterologist at the Brooklyn State Hospital
[90]. He was also a staff physician at the Seaview Hospital, Staten Island, NewYork;
consulting physician in Cumberland; Rockaway Beach Hospital; Long Beach
5.4 Eponymous Signs
150
Fig. 5.8 Przewalsky sign (by Ryan Yale)
5 Appendicitis: Somatic andVisceral Nerve Reexes Signs: Mechanisms…
151
Hospital, St. Joseph’s Hospital, Rockaway Beach and Post-Graduate Hospital,
Manhattan, NewYork City. Gray served as a lieutenant in the medical corps of the
United States Navy during World War I [87, 88, 90]. He was a member of the
Medical Society of the State of NewYork, the Kings County Medical Society,
American Medical Association, and the NewYork Heart Association [87, 91].
Gray reported on three cases by which pain in the left shoulder occurring in
patients with chronic appendicitis was caused reexively through the phrenic nerve.
The pathogenesis involved:
[a]n associated pylorospasm with increased gastric tension and upward pressure on the left
diaphragm which proved to be the cause of the phrenic shoulder pain [92, p.899]. In its
origin the phrenic nerve is in communication with the descending branches of the cervical
plexus. These branches become cutaneous near the clavicle. Thus we see how pain in the
left shoulder region may occur when the left phrenic nerve is irritated as a result of reex
pylorus spasm in chronic appendicitis [92, p.895].
Thus, Gray sign refers to pain in the left shoulder in patients with acute appendicitis.
The pathogenesis is presumably caused by peritonitis and diaphragmatic irritation
secondary to appendiceal perforation (Table5.1).
5.4.16 Iliescu Sign
We were unable to identify any historical information on Michail (Mihail) O.Iliescu.
At the time of the publication of his sign, he was an assistant surgeon in the depart-
ment of the Colentian Hospital, Bucharest [93].
Iliescu described a palpatory nding in patients with acute and chronic appendi-
citis (Table5.1):
I found pain on pressure at the right phrenic point, located in the neck between the two
heads of the sternocleidomastoid muscles. (…) [t]o nd it, one must look for it precisely in
the middle of the “phrenic triangle,” formed laterally by the two heads of the sternomastoid
and inferiorly by the internal segment of the clavicle. Perhaps the phrenic nerve cannot be
directly compressed, and only the terminal branches of the supercial cervical plexus is
compressed. The phrenic originates from the fourth, fth, sixth, and sometimes from the
third cervical nerves. Even though the pain was relatively supercial and cutaneous in some
cases that does not necessarily mean that the phrenic does not externalize the painful point
of the appendix in the neck. During my initial research, I believed that only the right phrenic
was positive, but now I must say that the two phrenic points are sensitive to pressure.
However, the right is incomparably more sensitive compared to the left. The patient is able
to distinguish this difference [93, p.315–316].
The sign was present in all of his 105 cases of acute and latent appendicitis, resolved
after an appendectomy, and was absent in patients with salpingo-oophoritis and
pelvic peritonitis [93]. The sign resolved when ice was applied and reoccurred when
the disease ared. He postulated that the nding was caused by ascending right
lymphangitis involving the phrenic nerve [93]. We are unaware of any study that
evaluated the sensitivity or specicity of this sign.
5.4 Eponymous Signs
152
5.4.17 Chapman Sign
Charles Leopold Granville Chapman (1876–1951) was born in Hessle, Yorkshire,
England, studied medicine at Guy’s Hospital, and was appointed member of the
Royal College of Surgeons, licentiate of the Royal College of Physicians in 1897, and
a fellow of the Royal College of Surgeons, England, in 1909 [94, 95]. He practiced
surgery in Grimsby, England, and in 1919 was appointed to the Grimsby and District
Hospital. He was a member of the Royal College of Obstetricians and Gynecologists
in 1934 and chairman of the Grimsby Division of the British Medical Association
from 1933 to 1934 [94, 95]. A description of his character as articulated in his obituary:
He was one of the best of that excellent type, the general-practitioner specialist. He main-
tained a high standard of surgery in the local hospital. (…) Doctors scattered throughout the
country will look back with gratitude and pleasure upon the warm hospitality which was
always afforded to them at his home in Grimsby [95, p.590].
Chapman described a method for diagnosing acute appendicitis and other condi-
tions which cause an acute abdomen with peritonitis:
The “rising test” consists in the patient putting both hands down by the side of the thighs
and then raising himself in bed by means of the abdominal muscles. This produces pain
immediately, and the patient fails to raise himself or complains of pain in doing so. This test
will prove positive when there is little or no tenderness in the abdomen. In my hands it has
frequently proved the presence of acute abdomen, and is often the decisive factor in doing
an immediate operation [96, p.786].
Thus, Chapman sign refers to pain occurring when the patient is asked to sit up from
a supine position (Table5.1). We are unaware of any study that evaluated the sensi-
tivity or specicity of this sign.
5.4.18 Sumner Sign
There is limited historical information on Franklin W.Sumner. He practiced surgery
at Dorset County Hospital, Dorchester, Dorset, England, and was elected fellow of
the Royal College of Surgeons, Edinburgh [97]. He described a sign in acute
appendicitis:
The patient lies on his back, limp, his arms by his sides, breathing freely with his mouth
wide open, his tongue protruded, and his glottis open (making no noise on respiration). The
warmed hand of the surgeon is than placed on the lower abdomen, the metacarpophalangeal
joints resting on the pubes and the ngers kept rigid, together extended, and pointing rst
to the right clavicle when examining the right side and to the left clavicle when examining
the left side; by a gentle movement of the metacarpophalangeal joints, wrist, and elbow, and
without any deep pressure of the phalanges, the muscle tone of the two sides is several times
compared, when it will be found that there is a denite increase of tone on the right side as
compared with the left [97, p.106–107].
Thus Sumner sign refers to the presence of increased abdominal muscle tone in
patients with peritonitis secondary to acute appendicitis (Table5.1). We are unaware
of any study that evaluated the sensitivity or specicity of this sign.
5 Appendicitis: Somatic andVisceral Nerve Reexes Signs: Mechanisms…
153
5.4.19 Brittain Sign
We were unable to identify any historical information on R.Brittain, an intern at the
Richmond Memorial Hospital, Virginia, USA, who observed in July 1928 a nding
in a patient with gangrenous appendicitis [98]. George Paul LaRoque (1876–1934)
named the sign in honor of Dr. Brittain, who was the rst to observe the nding and
to describe the examination technique which required that (Tab le5.1):
The patient should be quietly at rest, the bedclothes pulled well down, a careful inspection
made before the examining hand is applied and the patient’s mind diverted from the test.
Careful palpation of the left side and upper abdomen is made before the right lower quad-
rant is touched. Then, upon a gentle touch of the lower right quadrant, especially at the
McBurney area, as soon as the nger is applied the testicle is seen to retract upwards. As
long as the nger is held in contact the testicle remains in this position. As soon as it is
removed the testicle will drop back to its original position. It has been observed in some
cases that, with the hand remaining gently on the abdominal wall, the testicle may drop
back to its original position and then upon removal of the nger will again retract (rebound
retraction) [98, p.193–194].
LaRoque, who was a professor of clinical surgery at the Medical College of Virginia
and surgeon to Memorial, St. Philip, Dooley, Sheltering Arms and Retreat for the
Sick Hospital, Richmond, Virginia, reported that “We have now observed in nearly
500 cases of gangrenous appendicitis and have failed to observe it in more than 300
other acute abdominal affections, such as intestinal obstruction, gallbladder and
ulcer diseases, kidney and ureteral obstruction, and nonsurgical affection, such as
functional colicky pains, following dietetic indiscretions and the taking of purgative
medicine” [98, p.192]. LaRoque believed that this sign is pathognomonic for gan-
grenous appendicitis. He postulated that activation of the motor nerve reex arc
causes contraction of the cremasteric portion of the internal oblique muscle [98].
Thus, Brittain found that in male patients with gangrenous appendicitis, pressure
over the right lower abdominal quadrant caused contraction of the cremaster mus-
cle, drawing the testis into the upper portion of the scrotum. When the pressure is
released, the testis resumes its normal position (Table5.1). Summer wrote that “I
agree with LaRoque and Brittain that this sign is pathognomonic of a gangrenous
appendix in a high percentage of cases” [99, p.476]. We are unaware of any studies
that evaluated the sensitivity or specicity of this sign. The pathogenesis, although
not stated, may be secondary to irritation of the genital branch of the genitofemoral
nerve found in the right lower quadrant.
5.4.20 Fotheringham Sign
Wenceslao Tejerina Fotheringham (1901–1985) was born in Rio Cuarto, Cordoba,
Argentina [100, 101]. He was appointed physician to Albeto Baraldi Service at
Centennial Hospital [101]. Fotheringham was a full professor of surgical pathology
and associate professor of clinical surgery at the Rosario School of Medicine in
1940 [102]. The following year he was appointed head of the surgery service at the
Italiano Rosario Hospital [101].
5.4 Eponymous Signs
154
He served on the executive committee of the Fifth National Congress of Medicine
in Rosario in 1934, appointed to the Ofcial University Education Advisory Council
[101]. He was an honorary professor at the Universities of Montevideo and Santiago
de Chile. Fotheringham was a founding member of the Rosario Society of Surgery,
serving as its president from 1938 to 1939 and 1954 to 1955. He was elected president
of the Argentine Association of Surgery at the 21st Argentine Congress of Surgery [101].
Fotheringham reported a sign found in patients with acute appendicitis
(Table5.1):
We observed an acute nding involving the peritoneum in right iliac fossa, Apply full
downward pressure in the left iliac fossa and abruptly withdraw the hand, as if to investigate
Rovsing’s sign. The patient experiences an intense pain that radiates from the right fossa to
the navel or epigastric region, sometimes traversing the midline to the left side. When the
patient is asked where the pain is most severe, he sometimes points to the periumbilical
region. In some cases, the sudden decompression of the left iliac fossa is accompanied by
such intense pain that the confused and disoriented patient cannot accurately determine the
source of pain. Repeating the maneuver once or twice more requires the patient’s full atten-
tion to specify the radiation of pain [102, p.65–66].
Fotheringham believed that the radiation of the pain to the periumbilical region
when palpating and releasing the hand in the left lower quadrant is specic for acute
peritonitis. He acknowledged that this sign had been previously described but dif-
fered from the one he described (Table5.1):
Before concluding, I want to clarify that Jacob described a similar sign in acute appendici-
tis, a sign known by his name that consists of pain in the right iliac fossa caused by sudden
decompression on the left. Mondor stated that it is not just one more sign of peritonitis of
the iliac fossa since Jacob did not mention the umbilical or epigastric radiation of this pro-
voked pain that we judge to be of genuine diagnostic interest [102, p.67].
We are unaware of any study that evaluated the sensitivity or specicity of this sign.
5.4.21 Mastin Sign
Edward Vernon Mastin (1891–1962) was born in Mobile, Alabama, USA, and
received his medical degree from the University of Pennsylvania in 1916 and a
Master of Sciences in 1922. He completed an internship at the Polyclinic Hospital
from 1916 to 1917 and a surgical fellowship at the Mayo Clinic Rochester,
Minnesota, from 1917 to 1922 [103–106]. During World War I, he served with dis-
tinction in the Medical Corps of the U.S.Army and was discharged with the rank of
captain [103].
Mastin received his Master of Science degree in surgery at the University of
Minnesota in 1922 [103, 104]. He was appointed visiting surgeon at St. Louis City
Hospital and instructor in anatomy at Washington University, St. Louis, in 1926
[103]. He was an assistant professor of surgery at St. Louis University School of
Medicine, chief of surgery at St. Luke’s Jewish and St. Louis City Hospitals, assis-
tant surgeon at St. Mary’s and Firmin Desloge Hospitals, and consulting surgeon at
the Missouri Pacic and Frisco Employees’ Hospitals and Beaumont Medical
5 Appendicitis: Somatic andVisceral Nerve Reexes Signs: Mechanisms…
155
Building in St. Louis [103, 105, 106]. At the time of the publication of the sign,
which bears his name, he was a surgeon in the surgical department at St. Louis
University School of Medicine, St. Louis, Missouri [107]. He was a member of
several medical organizations, including the St. Louis Medical Society and Surgical
Societies and Southern Medical Association (president in 1945) [103, 104].
Mastin reported two cases who presented with right clavicular and shoulder pain
associated with nausea and vomiting. Palpatory pressure over the area of the acutely
inamed appendix exacerbated the pain, which was relieved after an appendectomy.
Mastin postulated that:
Relief of pain in the upper chest and shoulder region following appendectomy indicates that
the pain was caused by inammation of the appendix, consequently it was referred pain.
Since the areas to which the pain was referred is supplied by the third, fourth and fth cervi-
cal nerves, the afferent impulses arising at the site of inammation must have entered the
spinal cord in the corresponding cervical segments. The only nerve connected with this
segment of the spinal cord, which includes afferent bers that reach the abdomen, is the
phrenic. Consequently these must be regarded as cases in which the pain was referred via
the phrenic nerve [107, p.776].
Thus, Mastin sign refers right clavicular and shoulder pain in patients with acute
appendicitis with peritonitis (Table5.1). We are unaware of any study that evaluated
the sensitivity or specicity of this sign.
5.4.22 Richet - Netter Sign
5.4.22.1 Charles Richet
Charles Robert Richet (1850–1935) was born in Paris, France, and received his
medical degree from the Faculty of Medicine, University of Paris, in 1876. He was
appointed associate professor of physiology in the Faculty of Medicine, Paris, in
1877 and chair of physiology from 1887 to 1927 [108–110]. With the French physi-
ologist Paul Portier (1866–1962), he identied the immunologic phenomenon coin-
ing the term “anaphylaxis” in 1902 and was awarded the Nobel Prize for this work
in 1913 [108, 109].
Richet was the recipient of the Grand Cross of the Legion of Honor, a member of
the French Academy of Medicine in 1898 and the French Academy of Sciences in
1914 [108, 110]. He was editor of Revue Scientique from 1878 to 1902 and co-
editor of Journal de Physiologie et de Pathologie Générale beginning in 1917 [109].
He was editor of the 9-volume set of Dictionnaire de Physiologie from 1895 to 1912
[109, 110].
Richet was also a philosopher, poet, novelist, playwright, statistician, and engi-
neer [108, 110]. His view of eugenics and his position as president of the French
Eugenic Society, as expressed in his 1919 book La Sélection Humaine marred his
accomplishments and is contrary to the principles of an eponym being an honoric
term [111].
5.4 Eponymous Signs
156
5.4.22.2 Henry Netter
We were unable to identify any historical information on Henry Netter. Richet and
Netter identied the right thigh adductor muscle contracture in 40 of 50 patients
with acute or chronic appendicitis:
The patient is supine with the mouth open, thighs semi-exed, heels at on the bed, knees
adducted, and muscles completely relaxed. The hand or ngers are placed on the medial
surface of each knee. At the same time, pressure is directed outward to abduct the knees
such that their external surface is in contact with the bed as the mechanism to assess for
limitation of abduction. This maneuver must be performed by exerting soft, constant, and
equal pressure bilaterally without jerks [112, p.317]. The nding was independent of the
position, anatomical variations, or severity of appendicitis and occurred early and late in the
disease. They postulated that this condition was caused by a reex mechanism involving the
eleventh intercostal nerve. The authors noted that in most cases, there is only a slight con-
tracture or simple hypertonia, with abduction being less on the right side than the left side.
They recommend repeating the maneuver several times to appreciate the sensation of resis-
tance during abduction [112, p.318].
According to the authors, the sign was present in 40 of 100 children and adults with
acute appendicitis, including a case of appendicular abscess [112]. Thus, Richet -
Netter sign refers to the presence of hypertonia or contracture on abduction of the
right thigh (Table5.1).
5.4.23 Ben-Asher Sign
Solomon Ben-Asher (1894–1949) was born in Russia, immigrated to the USA, and
resided in New Jersey throughout most of his childhood and adult life. He received
his medical degree from the University and Bellevue Hospital Medical College
(renamed NewYork Grossman School of Medicine in 2019) in 1923 [113]. He
served as a cardiologist at Bellevue Hospital and a visiting physician at Greenville
Hospital, New Jersey. During World War I, he served in the Army with the Chemical
Warfare Branch in Washington, D.C.He was a member of the International and
American Gastroenterological Associations, an associate fellow of the American
College of Physicians, and a fellow of the American College of Chest Physicians
[113]. As described by Irving Willner, MD, Governor of the College of Chest
Physicians, New Jersey, “He was known as an inspiring and tireless worker by his
friends and patients” [113].
Ben-Asher described the “cough sign” as a method to diagnose acute appendicitis:
For many years, I have utilized the cough sign in the examination of acute abdominal cases
and have found it of great value in the differential diagnosis, and almost pathognomonic of
acute appendicitis. In eliciting the sign, the examiner places the tip of his ngers under the
left costal margin in the region of the spleen. The patient is then asked to take a deep breath,
exhale completely, and then cough. When positive, the patient will pin to the area of the
suspected appendicitis as the site of severe pain [114, p.369].
5 Appendicitis: Somatic andVisceral Nerve Reexes Signs: Mechanisms…