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197
Fig. 5.13 Baron sign (by Ryan Yale)
5.6 Eponymous Sign
198
5.6.32 Donnelly Sign
There is a paucity of information on Daniel Joseph Donnelly. He was a private prac-
titioner in gynecology, appointed instructor in materia medica in 1918, and was an
associate professor of medicine at Temple University, Philadelphia [256–258]. He
served as secretary and treasurer of the Samaritan Hospital Medical Society,
Philadelphia, in 1917 [259].
We were unable to identify the source text for Donnelly sign. Robertson and
Robertson wrote in their book Diagnostic Signs, Reexes and Syndromes, published
in 1947 (Table5.2):
Dr. Daniel Donnelly of Philadelphia has described a sign indicative of retrocecal appendi-
citis. When the right leg is in full extension and abducted, it causes the psoas muscle to be
brought into prominence. Pressure then made over the right inferior quadrant and especially
in and just below McBurney’s region elicits pain in proportion to the degree of inamma-
tion in the appendix and its surroundings [255, p.24].
This description suggests the activation of viscerosensory nerve pathways as the
mechanism of abdominal pain.
5 Appendicitis: Somatic andVisceral Nerve Reexes Signs: Mechanisms…
199
Table 5.2 Visceral reex signs in appendicitis
Name Year Description of the sign Method
Pathophysiologic
mechanism
Meltzer [131] 1902 Apply rm pressure over the tender spot on the anterior abdominal wall. When
pain occurs, release the pressure so that the patient experiences only minimal
discomfort. Now, ask the patient to ex the thigh
Palpation Viscerosensory
Sherren [136] 1903 1. In a location distant from the tender area, gently pinch or stroke the skin.
While moving inward toward the tender area, repeat this process and determine
its boundary. Cutaneous hyperalgesia is found either as a wide band extending
to the right side from the midline below the umbilicus in front to the lumbar
spine or as a small circular area slightly above the midpoint on a line drawn
between the umbilicus and anterior superior spine. Occasionally, the tenderness
extends to the gluteal region as a tongue-shaped band three inches in width.
2. Triangular area or “appendix triangle” of cutaneous tenderness in the right
iliac regions. Its lower boundary reaches almost to Poupart ligament. Its inner
almost extends to the middle line, and its apex is slightly outside the anterior
superior spine, sometimes extending to the mid-axillary line
Palpation Viscerosensory
Mackenzie [143] 1903 Excessive irritability of the nerve cell is responsible for the pain and
hyperesthesia in the tissues occurring on the abdominal wall. It is more readily
demonstrated in the erector spinae and muscles of the abdomen, particularly
those over the right iliac fossa. Pain occurs when slight pressure is applied to
this region. One can readily demonstrate that the tenderness is not due to the
inamed peritoneum by slightly raising a portion of muscle away from the
peritoneum before applying pressure or, in cases where the pain and tenderness
are widespread, by nding this tenderness in the muscles of the lumbar region
Palpation Viscerosensory
Sicard [146] 1905 A depression of the abdominal wall occurs on the same side where a supercial
touch is applied. The reexes are divided into an epigastric, paraumbilical, and
hypogastric zone and elicited by moving the nger from a central medial to a
lateral position. The paraumbilical and hypogastric reexes are involved in
appendicitis
Palpation Visceromotor
(continued)
5.6 Eponymous Sign
200
Table 5.2 (continued)
Name Year Description of the sign Method
Pathophysiologic
mechanism
Berthomier- Michelson
[149, 150]
1906
1911
A marked difference in pain intensity is found at the cecal-appendicular regions
depending upon whether the patient is positioned in the supine or left lateral
decubitus position. Palpation of McBurney point in the supine position showed
no evidence of chronic appendicitis, while palpation in the lateral decubitus
conrms the diagnosis
Palpation Viscerosensory
(chronic
appendicitis)
Rovsing [154] 1907 Compress the descending colon by pushing the ngers of the right hand onto the
ngers of the left hand placed at against the abdomen in the left iliac fossa.
Using this method, the hands slide upward toward the left colonic exure
Palpation Viscerosensory
Chase [161] 1908 Place the patient on a hard, low bed or table. Flex the knee and place two
pillows under the head and shoulders, giving a dorsal semi-recumbent position.
Stand on the patient’s left side, facing the feet. Place the palmar surfaces of the
ngers of the right hand under the patient’s left inguinal region and the ngers
of the left hand to reinforce the right hand. Deep pressure is applied gradually
backward, drawing the ngers deeply and forcibly upward under the left costal
arch. The intent of this maneuver is to compress the lower portion of the
descending colon and force its gaseous content into the transverse and thence to
the ascending colon. Maintain pressure with the ngers of the left-hand hand.
Remove the right hand, place it over the upper portion of the descending colon,
and apply more forcibly depression. A gaseous compression wave will travel
across the transverse and down the ascending colon and, on arriving at the
cecum, produces cecal distention, yielding a typical sharp pain in the right iliac
fossa if inammation of the cecum or appendix is present
Palpation Viscerosensory
Bastedo [170] 1910 Insufate air into the colon. Pain or tenderness in the region of McBurney point
on dilatation of the colon is consistent with appendicitis
Instilling air
in colon
Viscerosensory
Caden [40] 1911 Muscular rigidity is prominent in the lower right quadrant Palpation Visceromotor
Aaron [177] 1913 Continuous rm pressure applied with the rst three ngertips over McBurney
point induces referred pain in the epigastrium or precordial region
Palpation Viscerosensory
(chronic
appendicitis)
5 Appendicitis: Somatic andVisceral Nerve Reexes Signs: Mechanisms…
201
Name Year Description of the sign Method
Pathophysiologic
mechanism
Bassler [184] 1913 Identify the right edge of the rectus muscle with the nger, located on a line
extending from the umbilicus to the anterior superior iliac spine. Ask the patient
to rise to a sitting position. Stand to the right and face the patient (for right-
handed individuals). The thumb is placed vertically on the abdomen at the point
identied by the nger. Position the tip of the thumb pointing to the ensiform
and slowly press backward (not inward, outward, up, or down) into the
abdomen. With the thumb depressed about halfway down to the back of the
abdominal cavity, swing it to the patient’s right at a right angle to the downward
pressure line. This maneuver causes the appendix to become pinched against the
iliacus muscle and other xed structures located inferiorly and laterally
Palpation Viscerosensory
(chronic
appendicitis)
Reder [188] 1913 The patient is positioned supine with their legs exed. Insert a nger into the
rectum reaching for O’Beirne’s valve. The tip of the nger is allowed to rest
within the lumen of the valve, and the patient asked if he experiences any pain.
The answer is usually no. pain, if present, is generally referred to the sphincter
area of the rectum. This pain will subside after allowing the nger to rest for a
short time. (…) after being assured of the total absence of pain by the patient,
the tip of the nger is gently pushed upward toward the right iliac fossa. The
nger will touch a point beyond the valve that will cause signicant pain in the
case of appendicitis. Sweeping the examining nger toward the left inguinal
fossa is a control point. The location of the pain was not specied
Palpation Viscerosensory
(chronic
appendicitis)
Owen [192] 1914 Applying rm pressure with the hand over the descending colon causes gas
within the colon to be driven forcibly toward the cecum, and the patient will
complain of pain in the right iliac fossa. Steady pressure is maintained long
enough to move some of the gas out of the blind end of the large intestine. Then,
suddenly remove the hand. In that case, the rapid return of gas into the caecum
disturbs the inamed appendix so that the patient again complains of pain
Palpation Viscerosensory
(continued)
5.6 Eponymous Sign
202
Table 5.2 (continued)
Name Year Description of the sign Method
Pathophysiologic
mechanism
Wachenheim [196] 1916 To identify this point, gain the child’s condence, assuring them that the
procedure will not be distressing. Introduce the examining nger with
lubrication and slow dilation relatively painlessly into the rectum. The patient
does not complain of discomfort until the introduced nger reaches the right
iliac fossa. Here, the child complains of sharp pain in the neighborhood of
McBurney’s point. The child is asked to identify the site of the pain. If it is due
to the rough introduction of the nger, the patient will invariably point to the
anus. If appendicular, it is generally correctly localized, particularly in children
eight years and older. The location of the pain was not specied
Palpation Viscerosensory
Blaisdell [199] 1916 Pain increases in intensity when the patient turns to the left and diminishes
when they turn back to their right side. When performing the test, the abdomen
must not touch the bed to avoid supporting the viscera. The absence of support
to the viscera pulls it to the left and drags it along the sensitive appendix causing
additional pain. The location of the pain was not specied
Observation Viscerosensory
Baldwin [208] 1916 The examiner asks the patient to extend their knee and lift the right leg. The leg
drops, and the patient complains of pain. The location of the pain was not
specied
Passive Viscerosensory
Rosenstein [211] 1920 Place the patient in the left lateral decubitus position. Apply pressure to the right
side, three ngerbreadths inside and slightly below the right anterior superior
spine. The location of the pain was not specied
Palpatory Viscerosensory
Kocher [223] 1921 The initial vomiting and localization of pain is in the epigastrium, followed by
diffuse spread, and the gradual xation at McBurney point occurs because of
general peritoneal inammation
Observation Viscerosensory
Sloan [18, 223] 1922 The patient keeps their knee straight and 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 location of the
pain was not specied.
Palpatory Viscerosensory
5 Appendicitis: Somatic andVisceral Nerve Reexes Signs: Mechanisms…
203
Name Year Description of the sign Method
Pathophysiologic
mechanism
Gregory [74] 1922 Direct percussion at McBurney’s point is often painless in chronic appendicitis.
It has often been found that in chronic appendicitis, symptoms disappear after
palpation of the appendix, only to return after a few minutes
Palpatory Viscerosensory
Soresi [228] 1924 The examiner applies the hand to the region of the hepatic exure of the colon.
While the patient breathes as deeply as possible, the hand is pressed gently
under the costal margin. The patient is told to cough and asked whether they felt
any pain. If the answer is “yes,” the patient, on being asked where the pain is
felt, without hesitation, will indicate McBurney point when appendicitis is
present
Palpation Viscerosensory
Tresidder [230] 1925 The patient lies on their abdomen and, on being questioned, explains that they
found this was the most comfortable position from which they could lie. The
location of the pain was not specied
Observation Viscerosensory
Livingston [234] 1932 A noninvolved area of the skin is picked up between the thumb and forenger
and pulled directly away from the abdomen. Traction is maintained outward until
the patient reports discomfort. The initial degree of traction represents the
intensity standard for that particular patient. The pinch test applies vigorous
twisting pinches on all parts of the abdominal skin. An identical stimulus applied
to an inammatory area causes an immediate defensive response by the patient
(winces, cries out, or reaches for the examining hand). Testing with heat and cold
are further renements that may aid in determining the limits of hyperesthesia or
demonstrate the complete sensory change within the involved zone
Palpation Viscerosensory
Klein [239] 1938 Tenderness is located over a small area to the right of the umbilicus but higher
than McBurney point. The tender area may extend even above the umbilicus on
the right side. The left side is nontender. The patient is turned to the left lateral
decubitus position and remains for ≥30seconds. Palpation identies that the
tender area previously identied on the right side is absent and has now shifted
to the left of the umbilicus. The patient is now turned on their right side and
allowed to rest for a short period. Palpation in this position reveals absent left
and more marked tenderness on the right. Furthermore, the tender area is more
extensive in this position than when the patient rests on their back
Palpation Viscerosensory
(continued)
5.6 Eponymous Sign
204
Table 5.2 (continued)
Name Year Description of the sign Method
Pathophysiologic
mechanism
Altschüler [241] 1938 Place the third through fth ngers of the left hand on the outer border of the
ileum and the left index nger on the inner border. The index nger is gradually
moved downward over the soft parts from the anterior superior spine. A
circumscribed area of abdominal tenderness is present. In severe cases, there is a
localized muscle spasm in the exact location, or sometimes in a higher or lower
position, at the right pelvic margin. The abdomen wall is usually not sensitive to
pressure, and the usual points of tenderness are absent
Palpatory Viscerosensory/
visceromotor (acute
and chronic
retrocecal
appendicitis)
Alders [246] 1951 With the pregnant woman lying straight on her back, the examiner’s ngers
identify an area of maximum tenderness and applies pressure to the abdominal
wall. Ask the patient to turn toward the left decubitus position while maintaining
contact with the area of tenderness without altering the pressure exerted to elicit
pain
Palpation Viscerosensory
Bryan [249] 1955 Pressure on the pregnant uterus from the left side causes pain in the right lower
or middle quadrants
Palpation Viscerosensory
Arapov [252] 1968 With the ngers over the anterior abdominal wall, shallow pressure is applied
rst at a site distant 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 rectal and vaginal examination conrms whether the pelvic
peritoneum is also inamed
Palpatory Viscerosensory
Marek [253] 2021 The patient is placed in the left recumbent position with the knees and thighs
exed. In infants and children, rm pressure is applied to the anterior abdominal
wall in the lumbar region using the thumb directed posteriorly, while 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 push in the right hypogastrium
Palpatory Visceromotor
5 Appendicitis: Somatic andVisceral Nerve Reexes Signs: Mechanisms…
205
Name Year Description of the sign Method
Pathophysiologic
mechanism
Ott [254, 255] [n.a.] When the patient is on their left side, there is a feeling of distress and a painful
dragging sensation as if a heavy body in the abdomen had fallen to the left,
sometimes referred to as the “mesenteric pull.” The location of the pain was not
specied
Observation Viscerosensory
Baron [255] [n.a.] The patient is recumbent, relaxed, and told to breathe deeply. The examiner
places the second, third, and fourth ngers of their right hand on Poupart’s
ligament, and pressure is applied downward toward the psoas muscle. Ask the
patient to elevate the leg on the same side with the 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. For purposes of comparison,
apply similar palpation on both sides. Tenderness is more marked on the right
side when the appendix is involved
Palpation Viscerosensory/
visceromotor
Donnelly [255] [n.a.] The right leg is placed in full extension and abducted. Apply pressure over the
right inferior quadrant below (McBurney’s region). Pain elicited is proportional
to the degree of inammation in the appendix and its surroundings. The location
of the pain was not reported
Palpation Somatosensory
5.6 Eponymous Sign
206
5.7 Conclusion
Despite advanced imaging techniques, history and physical examination remain the
cornerstone in diagnosing acute and chronic appendicitis. There is an overlap in the
performance of some clinical signs and activation of the same nerve pathway. Gaps
remain in our knowledge regarding the reliability and validity of these signs in the
clinical diagnosis of appendicitis. These limitations involve not performing the sign
as initially described, lack of description or standardization of the maneuver, and
failure to correlate the location of the appendix and the extent of the disease with the
clinical examination. A further variation of these signs also depends on whether the
appendix is located in its most common retrocecal or retro-appendiceal position.
Clinicians performing these maneuvers must be aware of how they should be appro-
priately conducted, their limitations, pain location, and the signicance of a positive
test result. Knowledge of the fundamental anatomical aspects of the appendix, the
site of the pain, and the location of the inammatory process allows clinicians to
correlate pathophysiologic principles to the mechanism involved in a positive test.
These signs must be rigorously studied using a standardized methodology to further
clarify and elucidate their role and utility in clinical practice.
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5 Appendicitis: Somatic andVisceral Nerve Reexes Signs: Mechanisms…