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157
Ben-Asher did not describe the location of the pain in acute appendicitis (Table5.1).
In his study of 400 cases of patients with acute abdominal pain admitted to Greenville
Hospital, New Jersey, Ben-Asher identied 198 cases of uncomplicated appendici-
tis and 202 cases of non-appendiceal disease. The cough sign was identied in 71%
of patients with acute appendicitis and 24% with non-appendiceal disease [114].
5.4.24 Markle Sign
George Bushar Markle (1921–1999) was born in Hazleton, Pennsylvania, USA, and
received his medical degree from the University of Pennsylvania Medical School,
Philadelphia, Pennsylvania, in 1946 [115]. He completed an internship at Geisinger
Medical Center in Danville, Pennsylvania, and a surgical fellowship at the Mayo
Clinic in Rochester, Minnesota, in 1952 [115]. He served as a surgeon in World War
II and was Chief of Surgery stationed during the Korean War at Fort Monroe Army
Hospital, Virginia, from 1952 to 1954. He was a diplomate of the American Board
of Surgery and practiced surgery at Carlsbad Regional Medical Center, New
Mexico, from 1954 to 1994 [115].
Markle described the heel-drop jarring test, which is performed as follows
(Table5.1) (Fig.5.9):
The patient is asked to stand knees straight, with or without shoes. The clinician stands on
his toes for a few seconds and, relaxing suddenly, comes down with his full weight upon his
heels with a denite thump. The unsuspecting patient does likewise and may be quite sur-
prised to feel a denite pain wherever there is inammation in the abdomen. Not only can
he tell you usually quite positively, if there is pain, but also can tell just where the pain is
most severe [116, p.721].
Markle studied 43 patients with conrmed appendicitis and found rebound tender-
ness in 86% and a positive heel-drop jarring test in 93%. In those patients with a
positive sign, 92% were able to identify the location of their underlying disease
[116]. In another similar study (1985) by Markle, a positive heel-drop jarring test
was found in 74% of 190 patients with acute appendicitis, of which 71% were able
to identify the underlying source of inammation [117]. Ahn etal. (2016) found a
sensitivity and specicity of 69% and 65%, respectively, for the heel-drop jarring
test and a sensitivity and specicity of 59% and 63% for rebound tenderness [118].
Compared to other factors assessed in this study, the heel-drop jarring test had the
highest odds ratio of 3.4 [118]. A sensitivity and specicity of 85% and 30% posi-
tive heel-drop jarring test and odds ratio of 2.5 were reported by Menteş etal. (2010)
[119]. Combining other factors (white blood cell count ≥11.9/mm
3
and right lower
quadrant abdominal pain) with a positive heel-drop jarring test resulted in an odds
ratio of 9.75 with a positive predictive value of 96% in diagnosing acute appendici-
tis [119]. The lower specicity identied in these studies may reect the presence of
diseases involving the abdominal wall [118, 119]. Overall, the heel-drop jarring test
is useful for diagnosing acute appendicitis. Importantly, its utility is further improved
when combined with other ndings in acute appendicitis.
5.4 Eponymous Signs
158
Fig. 5.9 Markle sign (by Ryan Yale)
5.4.25 Dunphy Sign
John Englebert Dunphy (1908–1981) was born in Northampton, Massachusetts,
USA, and received his medical degree from Harvard Medical School in 1933. He
was trained in surgery at Peter Bent Brigham Hospital (currently Brigham and
Women’s Hospital) in Massachusetts and completed a fellowship at the Lahey
Clinic, Burlington, Massachusetts; Massachusetts General Hospital, Boston (George
Gorham Peters Traveling Fellow); and Harvard Medical School, Boston (Arthur
Cabot Research Fellow). He joined the faculty in the surgery department at Harvard
Medical School, practicing in the Newton-Wellesley area in 1939 [120, 121].
During World War II, Dunphy served as captain and commanding ofcer of the
surgical service of the Fifth General Hospital of the United States Army at Belfast
and Southern England [122]. He was chief of surgery in 1943, rising to the rank of
lieutenant colonel. For his meritorious service, he received the bronze star and
Commander of the Ordre de la Santé Publique (The Order of Public Health) from
the French government for his service to public health and protection. After the war,
he returned to his prior position at Harvard and Brigham Hospital as a part-time
senior associate professor [120].
5 Appendicitis: Somatic andVisceral Nerve Reexes Signs: Mechanisms…
159
Dunphy was appointed professor of surgery at Harvard Medical School and
was the rst director of the Fifth Surgical Service at the Boston City Hospital in
1955, where he was instrumental in establishing the Sears Surgical Laboratories.
He was appointed the Kenneth H.A.MacKenzie professor of surgery and chair-
man of the Department of Surgery at the University of Oregon in 1959 [122]. He
left Oregon and was appointed professor and chairman of the Department of
Surgery at the University of California, San Francisco, in 1964. It was here that he
established the trauma center and trauma research program. He also served as
associate chief of staff of education at the Veterans Hospital in San Francisco from
1975 to 1979 [121].
Dunphy received many awards and accolades, including ten honorary degrees
and six honorary fellowships in the Royal Colleges. He was one of the few sur-
geons who served as president of three surgical organizations—the American
Surgical Association, the Society of University Surgeons, and the American
College of Surgeons [120, 122]. A summary of Dunphy’s accomplishments and
character as in the words of Geoffrey Nunes, “Let us remember and honor
J.Englebert Dunphy—a skilled surgeon, an organization man, a jovial party man,
a caring physician, a curious biologist, an enthusiast teacher, and profound human-
ist who left a legacy that consists not only of surgical teaching but also of a body
of philosophy about patient care” [122, p.470]. In a tribute to Dunphy, Thomas
K.Hunt wrote:
His last written works were in support of the hospice concept and included a classic paper,
“On caring for the patient with cancer”. As he often did, he meant the word “caring” to have
two meanings—one professional, and one very personal. He truly cared for his patients.
Every resident who “cared” in a normally professional sense for one of Dunphy’s patients
learned how much Dunphy “cared” in the personal sense; and residents and colleagues alike
who became zealously professional were made to recognize quickly how important it was
“to care” in a personal sense as well [120].
Dunphy described a method for determining the presence of peritoneal inamma-
tion in his book Physical Examination of the Surgical Patient (Table5.1):
The patient should rst be asked to cough. In the presence of acute peritoneal inammation
this usually elicits a sharp twinge of pain localized to the involved area. It is extremely valu-
able to elicit the “cough tenderness” and have the patient point with one nger to the exact
area of pain. This localizes the area of inammation before the examiner so much as touches
the patient. He can thus avoid palpating this area until the remainder of the abdominal
examination is completed [123, p.137].
Golledge etal. (1996), in a prospective study of 100 consecutive patients presenting
with right lower quadrant abdominal pain, found 44 cases of histologically con-
rmed acute appendicitis and 14 with a normal appendix [30]. The cough test was
found to have a sensitivity of 82%, a specicity of 56%, a positive predictive value
of 56%, and diagnostic accuracy of 64% [30]. In a study of 866 patients with acute
5.4 Eponymous Signs
160
appendicitis, a sensitivity of 95.1% and specicity of 80% were found for Dunphy
sign [124]. Dixon etal. (1991) reported an odds ratio of 1.42 for abdominal pain
aggravated by coughing among 395 patients with histologically conrmed acute
appendicitis [125]. Although helpful in diagnosing peritonitis, these ndings sug-
gest that Dunphy sign lacks sufcient specicity to conrm the diagnosis of acute
appendicitis. Therefore, a negative sign should not exclude the diagnosis of acute
appendicitis.
5.4.26 Piulachs Sign
Historical information on Pedro Piulachs Oliva (1908–1976) is found in the small
and large bowel chapter. A sign or test (Piulachs ank pinch) and syndrome
(Piulachs-Hederich) have been eponymously named in honor of Piulachs. We were
unable to locate Piulachs’s paper on the ank pitch sign. Accordingly, “Pain caused
by compression of the right ank in the case of appendicitis. The maneuver is per-
formed by placing the thumb on iliac spine and remaining ngers in the direction of
the lumbar fossa” [126, p.237]. The right ank is then squeezed. A positive test
caused pain and abdominal guarding impeding hand closure. The same procedure
should be performed on the left ank.
5 Appendicitis: Somatic andVisceral Nerve Reexes Signs: Mechanisms…
161
Table 5.1 Somatic reex signs in appendicitis
Name Year Description of sign Method Pathophysiologic mechanism
McBurney [16] 1889 The site of greatest pain is identied by applying pressure in
the right lower abdominal quadrant using one nger at a
point located 1 1/2–2in. along a straight line extending from
the anterior spinous process of the ilium to the umbilicus
Palpation Somatosensory
Perman [23] 1904 1. Muscle tension at the cecum and adjacent abdominal
region when touched or lightly pressed
2. Pain localized to the ileocecal area when pressure is
applied to the left side of the abdomen
Palpation Somatomotor/somatosensory
Blumberg- Shchetkin
[25, 27]
1907
1908
Apply pressure to the abdominal area where the patient
complains of discomfort. Suddenly lift the palpating hand,
and ask the patient whether he/she experienced pain when
removing the hand. Ask the patient whether the pain worsens
when the hand is depressed or removed
Palpation Somatosensory
(continued)
5.4 Eponymous Signs
162
Table 5.1 (continued)
Illoway [38] 1908 The patient is supine on a table or sitting on a chair. Ask the
patient to ex the leg upon the thigh and the thigh upon the
trunk. Then ask if the movement, or rather the upward
pressure 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 further forcibly ex
the thigh upon the trunk or ask the patient to do so. Again,
inquire, does it cause pain or soreness, or does it increase the
pain or soreness? Now ask the patient to fully extend the leg
with a quick and rather sudden movement and inquire whether
this caused any pain or soreness. If neither of these
movements caused appreciable pain or soreness, ask the
patient to execute the same movements with the left leg and
compare the sensation produced to determine whether it is any
different from that caused by the right leg or whether it is the
same on both sides. If pain or soreness is present on exion
and extension—Place the more signicant importance on
extension—Regard it as a positive sign of appendicitis
Palpation Somatosensory
Caden [40] 1911 Muscular rigidity is prominent in the lower right quadrant Palpation Somatomotor
Chutro [48] 1912 The abdominal midline frequently deviates to the right with
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 with most
protruding point located at the umbilicus. Frequently it is
difcult to conrm the tracing of the midline. When
extending a thread from the xiphoid process to the middle of
the pubic symphysis, the entire navel is placed to the right of
the line as if it had moved laterally
Observation Somatomotor (supercial reex)
Name Year Description of sign Method Pathophysiologic mechanism
5 Appendicitis: Somatic andVisceral Nerve Reexes Signs: Mechanisms…
163
ten Horn [50] 1914 Grasp the spermatic cord between the thumb and index
nger above the testes, avoiding unnecessary pressure on the
testis. Gently pull the spermatic cord
Palpation Somatosensory
Lanz [53] 1914 The right cremaster reex is usually weakened or absent. In
acute cases, when the spermatic cord is rolled back and forth
as it exits the anterior inguinal ring at the medial attachment
of Poupart ligament just lateral to the pubic tubercle, it is
thick and exquisitely sensitive to pressure. When inserting a
nger into the inguinal canal, a greater tension in the right
anterior canal wall is felt compared to the left side, where
one can easily and painlessly insert the ngertip or the entire
index nger into the inguinal canal. The intensely stretched
inferior border of the inferior oblique and transversus muscle
on the right side prevents the penetration of the nger into
the inguinal canal. When attempting to perform the same
maneuver on the right side, it is painful, and not painful on
the left side. The patient complains of pain in coughing after
the nger is inserted into the inguinal canal
Palpation Somatosensory/somatomotor
Morris [56] 1917 The greatest tenderness on pressure is at the point ½ inches
to the right of the navel, close to the spinal column
Palpation Somatosensory
Cope [72] 1919 Obturator test. The examiner slightly exes the right thigh
and then internally and externally rotates the right hip. Pain
is located in the hypogastrium
Maneuver Somatosensory
Cope [59] 1921 Iliopsoas extension. The patient lies on the left side. The
examiner extends the right thigh. The location of the pain
was not specied
Maneuver Somatosensory
(continued)
5.4 Eponymous Signs
164
Table 5.1 (continued)
Gregory [74] 1922 Percussion midway between the umbilicus and anterior
superior iliac spine causes tremors of the small intestines
which is transmitted unimpeded (muscle contraction is
absent) to the diseased appendix, causing pain at
McBurney’s point. This symptom occurring in acute and
subacute appendicitis is pronounced—Slight percussion
causes an intense pain sensation at McBurney’s point. Direct
percussion at McBurney’s point is also usually painful in
acute and subacute appendicitis
Percussion Somatosensory (acute, subacute)/
viscerosensory (chronic
appendicitis)
Sattler [79] 1924 The patient is placed in a sitting position with the legs
horizontal position to the axis of the upper body. Ask the
patient to lift the right leg. In doing so, the patient exes the
hip joint, triggering isolated iliopsoas action. To accurately
perform the examination, extend the legs so that the
auxiliary muscles do not become active. 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, take hold
of the patient’s right leg and bend it further, asking him to
point using the examiner’s nger to the painful spot in his
abdomen. The point, which I call the “appendix 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)
Maneuver Somatosensory
Name Year Description of sign Method Pathophysiologic mechanism
5 Appendicitis: Somatic andVisceral Nerve Reexes Signs: Mechanisms…
165
Gray [85] 1925 Pressure is applied to the abdominal wall using the nger
pointed 11/2 inches below and to the right of the umbilicus.
This tender spot may have a small opening in the rectus
sheath. The amount of pressure required to produce
tenderness is estimated. The pressure is relaxed, and then
using the dorsum of the hand, diffuse pressure is made and
sustained over the appendix region. The same amount of
pressure is exerted at the exact location on the left side using
the point of a nger on the left hand.
Palpation Somatosensory
Przewalsky [86] 1925 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 2minutes. 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
Maneuver Somatomotor
Gray (shoulder) [92] 1925 Pain in the left shoulder Observation Somatosensory
(chronic appendicitis)
Iliescu [93] 1926 Pain on pressure occurs at the right phrenic point, located in
the neck between the two heads of the sternocleidomastoid
muscles. The pain occurs in the middle of the “phrenic
triangle,” which is formed laterally by the two heads of the
sternomastoid and inferiorly by the internal segment of the
clavicle. The right phrenic point is more sensitive compared
to the left
Palpation Somatosensory
Chapman [96] 1927 The patient places their hands down by the side of the thighs
and is asked to raise himself/herself in bed using only their
abdominal muscles
Passive Somatosensory
(continued)
5.4 Eponymous Signs
166
Table 5.1 (continued)
Sumner [97] 1930 The patient lies quietly on his/her back with the arms lying
by their side, breathing freely with their mouth wide open,
tongue protruding, and glottis open. The examiner places
his/her warm hand on the lower abdomen with the
metacarpophalangeal joints resting on the pubis. The ngers
are rigid, adducted, extended, and pointing rst to the right
clavicle when examining the right side and to the left
clavicle when examining the left side. Compare the muscle
tone of the two sides by gently moving the
metacarpophalangeal joints, wrist, and elbow without any
deep nger pressure
Palpation Somatomotor
Brittain [98] 1931 Carefully palpate the left side of the abdomen. Supercially
palpate the right lower quadrant at McBurney point. When
the nger is applied to this area, the testicle retracts upwards.
The testicle drops back to its original position as soon as the
nger is removed. In some cases, while the hand remaining
gently on the abdominal wall, the testicle may drop back to
its original position. Upon removing the hand, the testicle
retracts (rebound retraction)
Palpation Somatomotor
Fotheringham [102] 1934 Apply full downward pressure in the left iliac fossa and
abruptly withdraw the hand. The patient experiences intense
pain that radiates from the right fossa to the navel or
epigastric region, sometimes traversing the midline to the
left side. Ask the patient where the pain is most severe, and
he/she sometimes points to the periumbilical region. In some
cases, the sudden decompression of the left iliac fossa causes
such intense pain that the patient cannot accurately
determine the source of pain. Repeat the maneuver several
times to clarify the location of the pain’s radiation
Palpation Somatosensory
Name Year Description of sign Method Pathophysiologic mechanism
5 Appendicitis: Somatic andVisceral Nerve Reexes Signs: Mechanisms…