Dunphy sign

Statistical evaluation of the cough test

1994 – Bennett at al evaluated 150 consecutive patinets admitted to the emergency department with abdominal pain. The cough test determined abdominal peritonitis with sensitivity (78%); specificity (79%); and PPV (76%)

1996 – Golledge et al prospectively evaluated 100 consecutive patients with right lower quadrant pain with 44 patients having appendicitis (confirmed on histology) and 14 with normal appendix at operation. Cough test sensitivity (82%); specificity (52%); and PPV (56%).

2009 – Idris et al published a cohort study of 866 patients with cough test sensitivity (95%) and specificity (80%) for acute appendicitis.

History of Dunphy sign

Historically, Charles Heber McBurney (1845-1913) provided the first published documentation of the cough test in the diagnosis of appendicitis in 1891

…if firm pressure is made with the finger tip, and especially if the patient is made to cough while such pressure is being exerted, it is invariably easy to determine that the most sensitive point is a definite one in most cases. Generally the patient complains if the right thigh is overextended, and he will object if he is asked to cough.

McBurney 1891

In 1943 Dr Solomon Ben-Asher (1894 – 1949) reported on the value of the cough sign in diagnosing 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 tips of his fingers 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 point to the area of the suspected appendix as the site of severe pain. This sign is rarely mentioned in text books on medicine, nor is it emphasized in the voluminous literature on this disease.

The cough sign occurred almost three times as often in 70.7%) of the cases with acute appendicitis, as compared with 24.2 percent of the non-appendicial group.

Solomon Ben-Asher 1943

…as for the Dunphy eponym…

Many different options for this one…the most common derivation relates to one Osborne Joby Dunphy (1898–1989). However, I can find no reference to this individual, and no evidence of any publication relating to him or to his description of this sign.

John Englebert Dunphy (1908 – 1981) was an eminent American surgeon wrote in Physical Examination Of The Surgical Patient (in all four editions 1953-1975)

Pain elicited by coughing will be referred to the right lower quadrant

Dunphy 1953

The patient should first be asked to cough. In the presence of acute peritoneal inflammation this usually elicits a sharp twinge of pain localized to the involved area. It is extremely valuable to elicit this “cough tenderness” and have the patient point with one finger to the exact area of pain. This localizes the area of inflammation before the examiner so much as touches the patient

Dunphy 1975

Associated Persons

• John Englebert Dunphy (1908 – 1981)
• Charles Heber McBurney (1845 – 1913)
• Solomon Ben-Asher (1894 – 1949)

References

Original articles

• McBurney C. The Indications for Early Laparotomy in Appendicitis. Annals of Surgery. 1891; 13(4): 233–254.
• Ben-Asher S. The value of the cough sign in acute appendicitis. The American Journal of Digestive Diseases. 1943; 10: 368–370
• Dunphy JE, Botsford TW. Examination of the Abdomen: Acute appendicitis. In: Physical Examination Of The Surgical Patient. 1953: 123-124
• Dunphy JE, Botsford TW. Examination of the abdomen. III. The appraisal of abnormal findings. In: Physical Examination of the Surgical Patient. An Introduction to Clinical Surgery. 1975.136-146.
• Lewis FR, Holcroft JW, Boey J, Dunphy E. Appendicitis: a critical review of diagnosis and treatment in 1000 cases. Arch Surg. 1975; 110: 677-684.

Review articles

• Bennett DH, Tambeur LJ, Campbell WB. Use of coughing test to diagnose peritonitis. BMJ. 1994; 308(6940): 1336.
• Golledge J et al. Assessment of peritonism in appendicitis. Ann R Coll Surg Engl. 1996; 78(1): 11-4.
• Idris SA et al. The sensitivity and specificity of the conventional symptoms and signs in making a diagnosis of acute appendicitis. Sudan Journal of Medical Sciences. 2009; 4(1): 55-61.
• Eponymythology: Appendicitis eponymous signs. LITFL

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