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5.6.18 Kocher Sign
Emil Theodor Kocher (1841–1917) was born in Bern, Switzerland, and received his
medical degree from the University of Bern in 1866 [213]. He completed his post-
graduate studies in Zurich, Berlin, Paris, London, and Vienna. He habilitated in sur-
gery at the University of Bern and was appointed surgical assistant in the clinic to
George Albert Lücke (1829–1894). Kocher was a general practitioner and lecturer in
Berlin and was later appointed full professor and director of the surgical clinic at the
University of Bern in 1872, a position he maintained throughout his career [213–216].
His name is best recognized in connection with the treatment and management
of goiter, although he contributed substantially to other elds of medicine and sur-
gery [213, 217]. He also devised new surgical instruments and novel surgical tech-
niques for which his name is eponymously ascribed [218]. He was awarded the
Nobel Prize for his extensive work on the pathology, physiology, and surgical man-
agement of the thyroid gland in 1909 [219].
As a description of his character as articulated by Albert Kocher:
He was highly respected and loved by his students, as he knew better than anyone else how
to impart his unyielding rigor to everything that concerned the sick and thus combine
friendly collegiality with his students. His impeccable example and the ne, distinguished
way in which he imparted his knowledge to his students, modestly concealing his superior-
ity, spurred everyone on to the highest degree [216, p.7].
Among his numerous accolades, he was an honorary fellow of the Royal College of
Surgeons and an honorary member of the Royal Society of Sciences, Uppsala;
Swiss Natural Research Society; honorary member of the American Surgical
Society; president of the German Society of Surgeons, Berlin; and elected chairman
of the First International Congress of Surgeons, Brussels [215, 220].
Albert Vogel, a resident in Kocher’s surgical clinic, published Theodor Kocher’s
(1814–1917) work titled “Die Behandlung der Appendizitis an der chirurgischen
Klinik der Universität Bern” (The Treatment of Appendicitis at the Surgical Clinic
of the University of Bern) in 1921 was based on a presentation delivered by Kocher
at the inaugural meeting of the Swiss Society of Surgery on 8 March 1913. The
publication was delayed for one year due to the onset of World War I.The name
Kocher has been paired with Volkovich and is sometimes referred to as the Kocher-
Volkovich sign, which describes initial pain in the epigastrium, followed by pain in
the right lower quadrant [221–223]. Kocher reported:
In our opinion, initial vomiting, and localization of pain in the epigastrium followed by the dif-
fuse spread and gradual xation in the classical place, McBurney point, occurs because of
general peritoneal inammation. This inammation should not be confused with the serous type
of peritonitis which develops later if the appendix becomes gangrenous or perforates. We can
explain the diffuse pain, particularly at the umbilical and epigastric regions, because the appen-
dix is not painful in the rst stages of the disease, with the pulling on the peritoneum being the
source of pain. Local pain develops if inltration of the mesentery occurs [223, p.2–3].
As currently known, pain initially located in the epigastric and periumbilical regions
represents a viscerosensory nerve reex. In contrast, pain in the right lower
5.6 Eponymous Sign
188
quadrant is caused by viscerosomatic (visceromotor and viscerosensory) and
somatic (somatosensory and somatomotor) segmental reexes, the latter secondary
to inammation of the parietal peritoneum. Thus, Kocher described the classic pre-
sentation and sequence of events of acute appendicitis (Table5.2).
5.6.19 Sloan Sign
Leroy Hendrick Sloan (1892–1961) was born in Aurora, Illinois, and received his
medical degree from Rush Medical College, Chicago, Illinois, in 1917 [224]. He
completed an internship at Cook County Hospital in Chicago, Illinois, and furthered
his postgraduate training in Vienna and London. He returned to Chicago and
ascended to the chief of medical service at Illinois Central Hospital, a position he
held from 1921 to 1957 [224]. Other appointments in Chicago included attending
physician at Cook County Hospital, associate professor of Medicine at Rush
Medical College, and clinical professor of medicine at the University of Illinois
College of Medicine, Chicago [224].
Among his other accomplishments, he served as president of the American
College of Physicians and was chairman of the Joint Commission for Accreditation
of Hospitals [224]. His character as described by Ford K.Hick:
He had the gift of favorably affecting the lives of almost everyone with whom he came in
contact. He was a counselor, condant, and sponsor to many physicians. Any physician,
student or patient who really knew Dr. Sloan has some anecdote to recite expressing his
individuality and capacity for helping other people [224, p.601].
He described a maneuver for detecting appendicitis in patients with a heavy muscu-
lar abdomen (Fig.5.12):
The patient, keeping the knee straight, raises the right heel from the bed while the examiner
places his left hand over the right lower quadrant of the abdomen and applies pressure to it
with the ngers of the right hand. The psoas muscle is thus put on tension while the appen-
dix is compressed between it and the left hand of the examiner [18, p.142].
Sloan did not dene the location of the pain (Table5.2). The sign is similar to that
described by Meltzer in 1902 [131]. We are unaware of any study that evaluated the
sensitivity or specicity of this sign.
5.6.20 Gregory Sign
Historical information on Arthur Gregory is found under the section somatic seg-
mental nerve pathway signs. Gregory percussed midway between the umbilicus and
anterior superior iliac spine and found that:
In chronic appendicitis it is often necessary to use stronger percussion, sometimes with two
ngers, and to press in the abdominal walls with the ngers of the left hand, in order to
maintain the symptom. Some patients report that they do not feel any pain, but rather a
slight shaking or a light blow at McBurney’s point. Direct percussion at McBurney’s point
is also usually painful in acute and subacute appendicitis, but often completely painless in
5 Appendicitis: Somatic andVisceral Nerve Reexes Signs: Mechanisms…
189
Fig. 5.12 Sloan sign (by Ryan Yale)
5.6 Eponymous Sign
190
chronic appendicitis. It is possible that muscular contraction so reduces the transmission of
the shock to the diseased appendix that there is no sensation of pain at all. With percussion
on the left side, the vibration is transmitted unimpeded to the diseased appendix. It has often
been found that in chronic appendicitis symptoms disappears after palpation of the
appendix, only to return after a few minutes. It is possible that the intense sensation of pain
on palpation numbs the sensation of pain for a time [74, p.398].
Thus, Gregory recognized that in chronic appendicitis, no pain is found when per-
cussing over McBurney point. Pain is elicited when rm percussion and deep palpa-
tion are applied activating viscerosensory segmental reexes.
5.6.21 Soresi Sign
Angelo Luigi Maria Soresi (1877–1951) was born in Piacenza, Italy, received medi-
cal training in Naples and Rome, and graduated in 1903 [225]. He immigrated to the
USA, where he was a professor of surgery at Homeopathic Medical College, Flower
Hospital, and was later appointed chief surgeon at Green Point Hospital, Brooklyn,
NewYork. During World War I, he served as captain of the surgical department at
the Military Hospital, Green Cross (site of the elementary school of Torino) [225].
Among his accomplishments, he is credited for administering combined spinal epi-
dural anesthesia in 1937 and the surgical management of hiatal hernias [226, 227].
Soresi described a maneuver for diagnosing appendicitis (Tab le5.2):
The patient exes the thighs. The hand is applied to the region of the hepatic exure of the
colon. While the patient breathes as deeply as possible, the hand is pressed very gently
under the costal margin. The patient is told to cough, and is then asked whether any pain is
felt; the answer may be yes or no. When it is “yes,” the patient, on being asked whether the
pain is felt, without hesitation will indicate McBurney’s point when a true appendicitis is
present. (…) The sign is elicited through gently pressure on the appendiceal region by the
gas contained in the intestine, when the patient coughs, while the hand of the surgeon com-
presses the colon, and by the pressure of the contracting abdominal muscles [228, p.1766].
We are unaware of any studies which assessed the sensitivity or specicity of
this sign.
5.6.22 Tresidder Sign
Lieutenant Colonel Alfred Geddes Tresidder (1881–1970) received his medical
training at the London Hospital, qualifying in 1906 [229]. He graduated M.B.,
B.S. in 1907 and was a member of the Indian Medical Service, a military medical
service in British-ruled India, in 1908. Tresidder received his medical degree in
1911 [229]. He was appointed to the London Hospital as an ear, nose, and throat
(ENT) surgeon and received his Master of Science degree in 1931 [229]. After
World War I, he was a civil surgeon to the Bombay presidency, India, held the posi-
tion as major civil surgeon to Nasik, Hyderabad, Sindh, and Poona, and provided
medical care to Lord Lloyd (1879–1941), Governor of Bombay. Tresidder was
5 Appendicitis: Somatic andVisceral Nerve Reexes Signs: Mechanisms…
191
appointed Companion, Order of the Indian Empire in 1927 [229]. In approximately
1931, he was appointed surgeon to the Blackheath and Charlton Hospitals in South
East London and joined the Emergency Medical Service in 1939. He held a com-
mission as an ENT surgeon in the Royal Army Medical Corps, serving at Woolwich,
Netley, and Bath [229]. From 1946 to 1957, he served as a consulting ENT surgeon
at St. Helier’s Hospital and senior clinical assistant to the Central London, Throat,
Nose, and Ear Hospital. Tresidder remained active after retirement as a locum for
ENT surgeon and at the Post Ofce for the Treasury Medical Service. He rose to the
military rank of lieutenant-colonel [229].
Tresidder observed a nding in a 17-year-old male with an acute episode of
chronic appendicitis: “[t]he patient was lying on his abdomen and on being ques-
tioned he explained that he found that this was the most comfortable position on
which he could lie [230, p.376].” The appendix was found to be located retrocecally
and adherent to the posterior wall of the cecum. Tresidder postulated that
“Presumably the adoption of this position would allow the cecum to fall forward
and away from the inamed retro-caecal appendix, and in doing so relieve to some
extent the pressure on the organ” [230, p.376]. We are unaware of any studies
which assessed the sensitivity or specicity of this sign (Table5.2).
5.6.23 Livingston sign
Edward Meakin Livingston (1895–1969) was born in Sparta, Wisconsin, USA, and
received his medical degree from NewYork University in 1919 [231–233]. He was
an instructor in surgery in 1921, an assistant clinical professor of surgery, an assis-
tant visiting surgeon third division, and subsequently, an associate visiting surgeon
at Bellevue Hospital, New York [234]. He published with George T. Pack
(1898–1969) the books End-Results in the Treatment of Gastric Cancer: An
Analytical Study and Statistical Survey of Sixty Years of Surgical Treatment in 1939
and Treatment of Cancer and Allied Diseases in 1940 [235, 236]. During their later
writing, he was an assisting attending surgeon at Memorial Hospital in NewYork.
With Edward Milton Foote, he coauthored the sixth edition of Principles and
Practice of Minor Surgery: A Textbook for Students and Practitioners in 1929 (for-
merly named A Textbook of Minor Surgery by Edward Milton Foote) [237].
In the preface of his book A Clinical Study of the Abdominal Cavity and
Peritoneum in 1932, he stated:
So increased, however, has my estimate become of the diagnostic possibilities in the careful
bedside examination of the patient, that I already feel amply repaid for any expenditure of
time and effort. And if the reading of this volume there be those who derive even a small
degree of the pleasure which I have had in its preparation my payment shall have multiplied
[234, p. viii–ix].
Livingston described a triangular shape zone of cutaneous tenderness as “the most
important single sign or symptom of acute appendicitis” [238, p.630]. Based on
clinical observation, the area of skin tenderness was maximum at the center of the
triangle and does not extend beyond its borders. The appendix skin triangle consists
of the following:
5.6 Eponymous Sign
192
A line from the umbilicus to the highest point on the right iliac crest forms the upper side;
a line carried from this point to the right pubic spine forms its lower side, while a line from
the right pubic spine to the umbilicus closes the triangle [238, p.635].
Livingston acknowledged that other areas of cutaneous tenderness on the anterior
abdominal wall might occur in patients with appendicitis. However, a positive skin
test for the diagnosis of appendicitis is most likely when an area of hyperesthesia,
bordered by a triangular area with maximal tenderness in its center, is located in an
area in the right lower quadrant of the anterior abdominal wall. Sherren described a
similar triangular area of cutaneous hyperesthesia in the right lower quadrant in
patients with acute appendicitis [136].
Livingston emphasized that this bedside “pinch test” or “traction method” of
sensory testing should involve a vigorous twisting or pulling motion of the skin and
subcutaneous tissues between the thumb and forenger. Areas of noninvolved pain
should be tested for comparison, while heat or cold may be used to further assist in
dening the border of hyperesthesia or show a sensory change in the involved area.
In an observational study of 428 patients, acute appendicitis was conrmed in 367,
and 317 (86%) were found preoperatively to have cutaneous hyperesthesia limited
to the appendiceal triangle [238] (Table5.2).
5.6.24 Klein Sign
Limited historical information was identied for William Klein (1881–1970). He
was a member of the Department of Surgery at Morrisania City Hospitals and Bronx
Hospital, Bronx, NewYork, in 1938 [239]. Klein described a method for distin-
guishing acute appendicitis from acute mesenteric adenitis and other diseases
involving the cecum:
Tenderness is found over a small area to the right of the umbilicus, but much higher than
McBurney’s point. The tender area may extend even above the umbilicus on the right side.
The left side at the same time is free from tenderness. The patient is then turned on the left
side and allowed to remain in this position for thirty seconds or more. Palpation in this posi-
tion nds the tender area previously noted on the right side now shifted to the left of the
umbilicus and absent on the right side. The patient is turned on the right side and allowed
to rest for a short period, and palpation then reveals absence of tenderness on the left side
and more marked tenderness on the right. In this position the tenderness in the area in ques-
tion is more extensive than when the patient was resting on his back [239, p.578–579].
Klein accounted for the pathogenesis of this nding:
The shifting tenderness is easily explained if one remembers the anatomic outline of the mes-
entery. When the patient is turned on either side the mesentery of the small intestines will gravi-
tate to the extreme dependent part of the abdomen. The cecum and appendix have little mobility
and cannot be shifted to the left with a change of the body position. This one sign, when pres-
ent, has always differentiated mesenteric adenitis from acute appendicitis [239, p.579].
This sign is similar to that described by Berthomier-Michelson in 1906 and 1911,
respectively, Blaisdell in 1916, and Rosenstein in 1920. We are unaware of any
study that evaluated this sign’s sensitivity or specicity (Table5.2).
5 Appendicitis: Somatic andVisceral Nerve Reexes Signs: Mechanisms…
193
5.6.25 Altschüler Sign
Emil Altschüler (1879–1942) was born in Speyer in Rheiland-Pfalz, Germany, and
studied medicine in Heidelberg, Berlin, and Strasbourg [240]. He served as an assis-
tant physician at the Hygienic-Bacteriological Institute and Institute for Fighting
Typhoid from 1902 to 1904 and in 1904 as an assistant physician at Freimaurer
Hospital, Hamburg. Altschüler was an assistant and senior physician at the
University Surgical Clinic, Strasburg, and received his doctorate in 1909 [240]. In
Frankfurt am Main, he rose to chief surgeon at the Jewish Community Hospital.
During World War II, Altschüler immigrated to Israel and was appointed chief phy-
sician in the surgical department at Bikur Cholim Hospital, Jerusalem [240].
Altschüler described a nding in 1938in patients with acute and chronic retroce-
cal appendicitis:
The third, fourth, and little nger of the left hand are laid on the outer border of the ileum
and the left index-nger on the inner border. If the index-nger is very gradually moved
over the soft parts from the anterior superior spine downwards, every case of retrocoecal
appendicitis shows a denite, often very painful sensitivity, usually restricted to a small
area. In severe cases there is also very denite localized muscle spasm in the same place,
sometimes higher, sometimes lower. The abdomen is usually not sensitive to pressure and
the usual points of tenderness are absent [241, p.892].
Thus, the sign refers to pain and muscle spasm located over the right pelvic margin
in acute and chronic retrocecal appendicitis (Table 5.2). We are unaware of any
study that evaluated this sign’s sensitivity of specicity.
5.6.26 Alders Sign
Nicholas Alders (1904–1995) was born in Budapest, Hungary, and received his
medical degree from the University of Vienna in 1928 [242]. He practiced obstetrics
and gynecology in Vienna but was forced to ee to London, England, during World
War II.After qualifying in 1941, he served initially as a surgeon in the emergency
medical services and registrar in gynecological and obstetrics at the Royal Victoria
and West Hants Hospital, Bournemouth, England, and at the East Dorset Group of
Hospital, Southwest Metropolitan Regional Hospital Board, England, in 1954
[242–244]. He was appointed a fellow of the Royal College of Surgeons, Edinburgh,
in 1945; a member of the Royal College of Obstetricians and Gynecologists in
1951; and a fellow of the International College of Surgeons, Bournemouth, 1953
[242, 245]. Alders described a maneuver for differentiating uterine from extrauter-
ine (e.g., appendiceal) complications (Table5.2):
With the patient lying straight on her back, the examining ngers nd the area of maximum
tenderness to pressure on the abdominal wall. While the ngers remain in contact with that
area without altering the intensity of pressure, they are exerting to elicit pain, the patient is
made to turn over on the opposite side so that the plane of the anterior abdominal wall is
approximately vertical. The pain produced by the pressure of the ngers will be less or will
have entirely disappeared if the lesion is uterine and has fallen away from the examining
ngers—“shifting tenderness” [246, p.1194–1195].
5.6 Eponymous Sign
194
Alders did not specically state the location of the pain on palpation of the abdomen.
Based on the principle of viscerosensory segmental reex, it is postulated that the
pain is located along the T10–T11 dermatome. According to Alders, the pain caused
by uterine conditions, including hemorrhage or leiomyoma, becomes less intense or
disappears when the patient turns to the opposite side. If the pain is extrauterine in
origin, as in the case of appendicitis, ovarian torsion, or diverticulitis, it remains
unchanged when the patient moves to the left decubitus position. This nding occurs
because these are retroperitoneal structures and thus xed in position. Findings from
this maneuver are not helpful when there is an enlarged palpable uterus or where the
uterus is xed due to the adhesions to the abdominal wall. Studies evaluating Alders
sign are limited. One study by Chen etal. (1999) found Alders sign was present in
approximately 36% (5 of 14) of pregnant patients with acute appendicitis [247].
5.6.27 Bryan Sign
Williams McIver Bryan, Jr. (1917–2007) was born in Savannah, Georgia, and
received his medical degree from the Medical College of South Carolina in 1944
[248]. At the University of Tennessee College of Medicine, he received his Master
of Science degree and served as the Fred Adair Teaching Fellow in the Department
of Obstetrics and Gynecology [248]. He was chief in the obstetrics and gynecology
department at Columbia General Hospital, South Carolina (currently Prisma Health
Richland Hospital). Bryan also served as a consultant at Baptist Medical Center
(currently Prisma Health Baptist), Richland Memorial (currently Prisma Health
Richland), and Providence Hospitals, Columbia [248].
Among his other accolades, he served as president of the South Central Obstetrical
and Gynecological Society, diplomate and Life Fellow of the American College of
Obstetricians and Gynecologists, and a fellow of the American College of Physicians
[248]. He was also a member of the board of directors for the American Red Cross
United Fund and the committee for Maternal Welfare for the State of South Carolina [248].
In his discussion of appendicitis during a presentation at the 17th Annual Meeting
of the South Atlantic Association of Obstetricians and Gynecologists, Bryan reported
a method for diagnosing appendicitis during pregnancy and the puerperium that
involved applying “Pressure on the pregnant uterus from the left side will often elicit
pain in the right lower or middle quadrants” [249, p.1205]. The presence of pain in
this location suggests activation of the viscerosensory segmental pain reex caused
by compression of the gravid uterus on the inamed appendix. Kurtz etal. reported
the presence of Bryan sign in 31 of 37 (83.8%) followed by rebound tenderness in
24 of 35 (68.6%) cases of appendicitis occurring during pregnancy [250] (Table5.2).
5.6.28 Arapov Sign
Dmitry Alekseyevich Arapov (1897–1984) was born in Moscow, Russia, and
received his medical degree from the Medical Faculty of the Second Moscow State
University in 1929. He served at the Nikolai Vasilyevich Sklifosovsky First Aid
5 Appendicitis: Somatic andVisceral Nerve Reexes Signs: Mechanisms…
195
Research Institute in Moscow under the aegis of Sergei Yudin (1891–1954), chair-
man of the surgical department [251]. He was appointed deputy chief surgeon of the
military medical directorate of the ministry of defense and chief surgeon of the
USSR Navy from 1953 to 1970 [251].
His most highly recognized works were related to gas gangrene caused by axil-
lary fragments lodged in a wound and the use of nitrous oxide to prevent shock.
Arapov was appointed corresponding member of the USSR Academy of Medical
Science in 1953, an honored scientist of the Russian Soviet Federative Socialist
Republic in 1959, an honorary member of the All-Russian, Moscow, Kazakh, and
Tajik Surgical Societies, and a member of the International Society of Surgeons. He
received many honors and awards, including the Order of the Red Banner, the Red
Star, and the Badge of Honor and Medal [251].
Arapov etal. described a physical nding in patients with acute appendicitis
(Table5.2):
Irritation of the peritoneum is determined according to this rule: The hand is used to apply
supercial pressure over the anterior abdominal wall at a distance from the right iliac fossa.
Pain after deep and sharp pressure at the right ileal fossa conrms that the appendix, not the
peritoneum, is involved. The absence of irritation of the pelvic peritoneum, as determined
by rectal and vaginal examination, provides additional information [252, p.25].
Arapov did not delineate the location of the pain. We are unaware of any study that
evaluated this sign’s sensitivity of specicity.
5.6.29 Marek Sign
Vitezslav Marek is currently a member of the Department of Surgical Oncology, St.
Elizabeth Hospital, Medical School of Comenius University, Bratislava, Slovak
Republic [253]. Marek etal. (2021), in their paper titled “Acute appendicitis: clini-
cal anatomy of the new palpation sign,” introduced a novel viscerosomatic palpatory
sign used in the diagnosis of acute appendicitis [253]. The authors’ method is unique,
and the technique was modied slightly for infants and children. Patients are placed
in the left recumbent position with knees exed, which displaces the mesentery
slightly to the left, providing better palpatory access to the appendix, while exion
of the knees and thighs relaxes the anterior abdominal wall. In infants and children,
the technique involves applying rm pressure on the anterior abdominal wall in the
lumbar region using the thumb directed posteriorly while simultaneously palpatory
pressure is applied in the right hypogastrium region using the second, third, and
fourth ngers of the same hand. A bimanual method in adults involves applying the
same technique with the thumb, but in this case, the ngers of the left and right hand
are used to apply pressure in the right hypogastrium. According to Marek etal., “If
a deep palpation induces abdominal contracture, preventing the palpation of the iliac
artery pulsations, the sign is considered positive, indicating a high probability of AA
and the need for a surgical revision” [253, p.219].
The authors state that the sign can be used during the early and later stages of
appendicitis and involves the activation of visceromotor segmental reexes. It is
5.6 Eponymous Sign
196
recognized that these segmental reexes become clinically indistinguishable in
cases of acute appendicitis with perforation causing secondary inammation of the
parietal peritoneum. In cases of inammation of the parietal peritoneum, abdominal
wall contraction occurs during supercial palpation (somatomotor segmental
reex). Thus, conditions other than acute appendicitis, which causes peritonitis and
impedes palpation of the iliac artery pulsation, will cause a false-positive Marek
sign. We are unaware of any study that evaluated this sign’s sensitivity or specicity
(Table5.2).
5.6.30 Ott Sign
We were unable to verify the author’s identify or source text for Ott sign. According
to Donnell B.Cobb, Ott sign:
[i]s obtained by having the patient turn on the left side, thus producing a painful dragging
sensation on the right lower quadrant as the cecum and inamed appendix tend to sag
toward the left and pull against the mesentery [254, p.476].
Robertson and Robertson (1947) referred to Ott sign (Table5.2):
When the patient is on his left side there is a feeling of distress and of a painful dragging
sensation as if a heavy body in the abdomen had fallen to the left, sometimes referred to as
the “mesenteric pull” [255, p.19].
Thus, Ott sign refers to the dragging sensation in the right lower quadrant when the
patient is placed in the left lateral decubitus position.
5.6.31 Baron Sign
We were unable to identify the text source and biographical information of the
Baron sign. According to Robertson and Robertson (1947), Baron found in chronic
appendicitis that the (Fig.5.13):
[r]ight psoas muscle was frequently sensitive to pressure. The patient must be recumbent,
relaxed and told to breathe deeply. The examiner’s second third and fourth ngers of the
right hand are placed on Poupart’s ligament and pressure is made in the direction of the
psoas muscle. The patient is told then to elevate the leg of the same side with knee extended,
forming an angle at the hip of about 45 degrees. In this position the palpating ngers readily
detect the psoas muscle thus made tense. Similar palpation should be made on both sides
for purposes of comparison; even in the healthy individual the tensed muscle may be sensi-
tive, but when the appendix is involved, the tenderness is more marked on the right side.
However, the psoas, in being covered by the peritoneum, is also painful in the presence of
sacrospinal and gluteal muscle myalgias-in arthroses of the lumbar region of the spine, the
lumbosacral and ileosacral joints and sometimes in sciatica [255, p.22] (Table5.2).
Thus, Baron sign refers to the viscerosensory reex elicited through palpation and
extension of the leg.
5 Appendicitis: Somatic andVisceral Nerve Reexes Signs: Mechanisms…