Clinical Medicine & Research Volume 16, Number 3-4: 83-91 ©2018 Marshfield Clinic Health System clinmedres.org History of Medicine Abdominal Physical Signs and Medical Eponyms: Physical Examination of Palpation Part 1, 1876-1907 Vaibhav Rastogi, MD; Devina Singh, MD; Halil Tekiner, PhD; Fan Ye, MD; Nataliya Kirchenko, MSc; Joseph J. Mazza, MD; and Steven H. Yale, MD Background: Abdominal palpation is a difficult skill to master in the physical examination. It is through the tactile sensation of touch that abdominal tenderness is detected and expressed through pain. Its findings can be used to detect peritonitis and other acute and subtle abnormalities of the abdomen. Some techniques, recognized as signs or medical eponyms, assist clinicians in detecting disease and differentiating other conditions based on location and response to palpation. Described in this paper are medical eponyms associated with abdominal palpation from the period 1876 to 1907. Data Sources: PubMed, Medline, on-line Internet word searches, textbooks and references from other source text were used as the data source. PubMed was searched using the Medical Subject Heading (MeSH) of the name of the eponyms and text words associated with the sign. Conclusion: We present brief historical background information about the physician who reported the sign, original description of the sign, and its clinical application and implication in today’s medical practice. Keywords: Palpation; Abdomen; Signs; Eponyms alpation, or the Latin verb palpates, meaning to touch, Using the dorsum of the hand, palpation is able to detect is a tactile sensation and an important but often changes in skin temperature and texture; it is performed using overlooked part of the physical examination of the both superficial and deep techniques. P 1 abdomen. It is the third skill performed in the systematic sequence of the physical examination preceded by inspection Superficial palpation focuses on detecting abnormalities and auscultation and followed lastly by percussion. within the abdominal wall, feeling for crepitation, masses, Auscultation precedes palpation in the abdomen due to spasms or eliciting tenderness.3 Superficial palpation for concerns related to stimulation of bowel movement, thereby detecting spasm of the recti muscle is identified using a two- falsely enhancing bowel sounds. Palpation uses the flat flexor hand technique whereby the flexor surface of the fingers of surface of the fingers with the forearm maintained in a strict the left hand are in contact with the muscle and depressed horizontal position, feeling for abnormalities in the abdomen with the right hand. Deep palpation using the flexor surface of such as tenderness, consistency, induration, and detecting the fingers with the hand tilted at a slight angle is particularly 2 depth and fixation of organs, hematomas, and abscesses. useful for detecting and evaluating a mass and is performed Corresponding Author: Steven H. Yale, MD, MACP, University of Central Florida Received: March 17, 2018 College of Medicine, 6850 Lake Nona Blvd, Orlando, FL 32827, Revised: June 2, 2018 Email: [email protected] Accepted: July 17, 2018 doi:10.3121/cmr.2018.1423 83 using a one hand or two hand technique. To localize an area Rosenbach (1876) (Table 1) described his finding when of tenderness, gentle systematic palpation of the abdomen stroking the skin of the abdominal wall in a patient with using the index finger is employed.4 This paper describes cerebral hemiplegia as “If the method described is applied to medical eponyms associated with palpation of the abdomen. hemiplegia of cerebral origin, there is no such abdominal Presented are brief historical aspects, performance, clinical reflex on the paralyzed side as I would call the phenomenon, application, and implication of these signs. The signs are while on the healthy side it remains unchanged and prompt.”12 presented systematically based on the year they were (p. 846; emphasis added) We are unaware of any study that evaluated originally described. the sensitivity or specificity of this sign. Data Sources McBurney Sign PubMed, Medline, online Internet word searches, and Dr. Charles Heber McBurney (1845-1913) was born in bibliographies from source text and textbooks were used. Roxbury, Massachusetts, graduated from Harvard University PubMed was searched using the Medical Subject Heading in 1866, and received his MD degree from the College of (MeSH) of the name of the eponyms and text words Physicians and Surgeons at Columbia University, New York in associated with the sign. 1870.13,14 After completing an internship at Bellevue Hospital in New York City, he traveled to Vienna, Paris and London for Rosenbach Sign additional medical training.14 In 1873, he returned to the Ottomar Ernst Felix Rosenbach (1851-1907) was born in College of Physicians and Surgeons serving as Assistant Krapkowice, Schlesien Prussian County in Silesia, completed Demonstrator in Anatomy.9 In 1880, he was appointed assistant his medical studies in Breslau and Berlin, and received his surgeon in Bellevue and in 1888, surgeon-in-chief at Roosevelt medical degree in Breslau in 1874.5 He was an assistant from Hospital, New York City.9 He was Professor of Surgery at the 1874 to 1887 at the University Hospital in Jenna in the College of Physicians and Surgeons from 1889 to 1894.14 He medical hospital and dispensary. He served as head physician described the sign that bears his name at the New York at Breslauer Allerheiligen Hospital from 1887 until 1893 and Surgical Society in 1889, soon after Dr. Reginald Fitz reported moved his medical practice to Berlin in 1896, further the pathologic finding of the vermiform appendix at the allowing him to pursue his research interests and scientific Association of American Physicians first meeting in 1886, work.5,6 Rosenbach published 278 books, monographs, naming the condition appendicitis.14 McBurney also described treatises, and papers, and among his many accomplishments, the incision for appendectomy that became known as the he was first to recognize functional disease of the stomach. McBurney incision, which involved splitting rather than He authored the book Über musikalische Herzgeräusche- cutting the muscle bundles of the external and internal oblique, Nebst Bemerkungen über die Entstehung pseuddokardialer aponeurosis, and tranversalis muscles to access the appendicitis Geräusche (About Musical Heart Noises-Along with Remarks in patients with acute, non-perforated appendicial disease.15 on the Origin of Pseudo-Cardiac Noises) describing the pathophysiology of heart murmurs based on his clinical In his 1889 paper, "Experience with Early Operative experience, postmortem investigation, and experimental Interference in Cases of Disease of the Vermiform Appendix," research.7 Using these skills, he developed the first animal Dr. McBurney reported: model for endocarditis in 1887 and was the first, along with The seat of greatest pain, determined by the pressure of one Karl Koester, to recognize the relationship that abnormalities finger, has been very exact between an inch and half and two of the cardiac valves predispose to the development of this inches from the anterior spinous process of the ilium on a disease.8 He also described the findings of vocal cord straight line drawn from that process to the umbilicus.16 (p. 678; paralysis after partial or complete paralysis of the recurrent emphasis added) (Table 1) laryngeal nerve.9 A Rose, MD (1907) described him as one whom: It is of historic interest that Ludwig Taube described in 1871 a (…) always considered it one of his principal tasks to case in "Entzündung des Bindegewebes und des Peritonäum in support the unification of the medical practice as opposed der Umgegend des Coecum mit Fäcal-Obstruction des Colon" to the ever-increasing division into special branches, thus (Inflammation of Connective Tissue and Peritoneum in the favoring the idea of allotting to the general practitioner the Area of the Cecum with Fecal Obstruction of the Colon) of a entire domain of medicine.10 (p 859) previously healthy man, aged 32 years: It began with a body-pain, which at first appeared in the As a tribute to Dr. Rosenbach, A Rose, MD (1907) wrote: lower half of the abdomen, between the middle of the [a]ll will agree that among the prominent men of our anterior superior spine and navel, at first moderately, but profession and our time, Rosenbach was, more than any already reaching a great severity later, and continuing to other, an original thinker, observer and investigator, who increase in intensity by late noon yesterday.17 (p. 55) made no concessions to the extravagant fashions in medicine of the present day.11 (p. 367) Two days later he wrote, “Abdomen is very much distended, tense, and sensitive everywhere to pressure, to the right more strongly, to the point mentioned above between iliac spine and 84 Abdominal palpation signs 1876-1907 CM&R 2018 : 3-4 (December) Table 1. Summary of Abdominal Physical Signs of Palpation from 1876 to 1907. Sign Year Description Sensitivity Specificity In cerebral hemiplegia, absence of the abdominal wall skin Rosenbach 1876 reflex when stroking the skin of the abdomen on the Unknown Unknown paralyzed side. Pain on abdominal palpation caused by applying pressure of one finger located between an 1 ½" and 2 ½” based on a McBurney 1889 83% 45% straight line drawn from the anterior spinous process of the ilium (ASIS) to the umbilicus. The absence of gallbladder dilation caused by a gallstone 26%-55% 83%-90% Courvoisier 1890 and its presence as due to other causes of obstruction (eg, (for (for malignancy). malignancy) malignancy) Pressure point tenderness located at the 12th thoracic vertebra extending to a region 2 or 3 finger-breadths distant Boas 1890 7% Unknown from the vertebral bodies; spreading from this point to the right, and in some case to the posterior axillary line. (1) Pain on deep palpation located just below the right 9th costal cartilage or at a point located at the junction of a vertical line drawn from the middle of the inguinal ligament to the 9th costal cartilage.