Rovsing sign: The current use of this eponymous sign, particularly in English literature, describes right lower quadrant pain elicited by palpation of the left lower quadrant in acute appendicitis. If this occurs, it is said to be a positive Rovsing sign; or more correctly the Perman-Rovsing sign, or the Perman sign.
The Rovsing sign is described variably in medical literature with most descriptions bearing little/no resemblance to the 1907 description by Rovsing, but rather the description offered by Emil S. Perman in 1904.
The true Rovsing sign described by Rovsing in 1907 describes a manoeuvre which attempts to distend the caecum and appendix by applying pressure to the left colon, in an anti-peristaltic fashion. The left hand is pressed into the left iliac fossa whilst the right hand strokes upwards towards the splenic flexure to indirectly distend the caecum, and thus stimulate pain in cases of appendicitis.
History of the Perman-Rovsing Sign
1871 – Ludwig Traube described a case of puncture of the appendix with cataclysm. He noted peritonitis secondary to perforated appendix may cause pain on palpation the left iliac fossa.
…weder die Schmerzen noch die krankhafte Empfindlichkeit gegen Druck sich in der Regio iliaca dextra am stärksten bemerklich machten. Es ist schwer, über die Ursache dieser Erscheinung Rechenschaft zu geben; denn wollten wir sie davon ableiten, dass der Entzündnngsheerd wegen seiner zu grossen Entfernung von der Bauchwand der Palpation in der Regio iliaca dextra nicht recht zugängig war, so durfte noch viel weniger ein Schmerz durch Druck auf die Regio iliaca sinistra hervorgerufen werden. Doch dem sei wie ihm wolle, jedenfalls sehen wir, dass eine von Durchbohrung des Wurmfortsatzes abhängige Peritonitis recht wohl vorhanden sein kann, ohne dass die Schmerzen und die krankhafte Empfindlichkeit gegen Druck ihren Hauptsitz in der Regio iliaca dextra zu haben brauchen.
…neither the pain nor abnormal sensitivity to pressure was present in the right iliac region. It is difficult to account for the cause of this phenomenon. It can be deduced that the inflammatory process was not quite accessible because it was at a greater distant from the abdominal wall and therefore could not be palpated in the right iliac fossa. Pain could be produced by palpatory pressure in the left iliac fossa. However, whatever the case may be, we can see that peritonitis caused by perforation of the appendix may be present, even though the pain and the morbid sensitivity to pressure may not present in the right iliac region.
1904 – Emil S. Perman published his original brief description of pain located to the ileoecal tract with pressure in the left part of the abdomen with appendicitis.
His findings were published in a paper, titled “Om indikationerna för operation vid appendicit samt redogörelse for å Sabbatsbergs sjukhus opererade fall“, detailing 244 cases of appendicitis between 1899-1904 at Sabbatsberg Hospital in Sweden, and the indications of surgery in appendicitis. His original description appears on page 806 of the article:
Därpå har jag äfven alltid funnit ett annat symtom tyda, nämligen en till ileooekaltrakten lokaliserad smärta vid tryck å- vänstra delen af buken.
Furthermore, I have always found another symptom evident, namely a pain located to the ileocaecal tract with pressure to the left part of the abdomen
1907 – Although this sign is commonly taught to be attributable to eliciting peritoneal irritation, Rovsing’s original description and intention were quite different. Rovsing originally described the manoeuvre as an attempt to distend the caecum and appendix by applying pressure to the left colon, in an anti-peristaltic fashion.
The left hand is applied over the healthy colon in the left iliac fossa, the right hand applies pressure over it in an antiperistaltic direction; because the ileo-caecal valve is competent, pain is produced in the right iliac fossa with inflammation of the appendix and caecum. Where there is muscular rigidity in the right iliac fossa and therefore accurate palpation is impossible, it will give a clue to the diagnosis-that is, it will differentiate between a lesion of the caecum and the appendix in the right iliac fossa from another lesion giving inflammation in the right iliac fossaRovsing 1907
In doing this correctly, Rovsing suggests that if pain is elicited, then this isolates the source to the caecum or appendix, and rules out other structures in the right iliac fossa.
I press with my right hand onto the fingers of the left hand that is lying flat against the colon descendens [descending colon] and then let the hand glide up toward the splenic flexure…The entire method is based upon isolated rise of pressure within the colon.Rovsing 1907
The Rovsing sign is described variably in medical literature with most descriptions bearing little/no resemblance to the 1907 description by Rovsing, but rather the description offered by Perman in 1904.
2014 – Prosenz et al reviewed 1178 individual studies and found no included study correctly described the method of eliciting Rovsing sign. Of 9 textbooks reviewed, 3 English texts on surgery failed to described the sign accurately, however all 6 German (text)books provided an accurate description.
- Perman ES. Om indikationerna för operation vid appendicit samt redogörelse for å Sabbatsbergs sjukhus opererade fall. Hygiea 1904; 66(2): 797-847 [Perman symptom p806] Translation: Mads Advastad
- Rovsing T. Indirektes Hervorrufen des typischen Schmerzes an McBurney’s Punkt. Ein Beitrag zur Diagnostik der Appendicitis und Typhlitis [Indirect elicitation of the typical pain at McBurney’s point. A contribution to the diagnosis of appendicitis and typhlitis]. Zentralblatt für Chirurgie 1907 ;34: 1257-59 [Rovsing sign]
- Bastedo WA. The dilatation test for chronic appendicitis. American Journal Of The Medical Sciences. 1911; 142: 11-14 [Bastedo sign]
- Hertz AF. Bastedo’s sign: A new sign of chronic appendicitis. Lancet 1913; 181(4673): 816-817
- Davey WW. Rovsing’s sign. Br Med J. 1956; 2(4983): 28-30.
- Smith PH. The Diagnosis of Appendicitis. Postgrad Med J. 1965 Jan; 41(471): 2–5.
- Ráf L. Skandinaviska kirurger först med beskrivning av tecken pâ appendicit. [The men behind the syndrome: Emil Perman and Nils Thorkild Rovsing. Scandinavian surgeons were the first to describe signs of appendicitis] Läkartidningen 1984; 81(32-33): 2829-30
- Lewis, SRR. Appendicitis BMJ 2011; 343: d5976
- Hognason K, Swan KG. Niels Thorkild Rovsing: the Surgeon Behind the Sign. Am Surg 2014 12; 80(12): 1201-1206
- Prosenz J, Hirtler L. Rovsing sign revisited-effects of an erroneous translation on medical teaching and research. J Surg Educ. 2014 Sep-Oct;71(5):738-42
- McKennedy C. Rovsing sign. Eponym A Day. Instagram
- McKennedy C. Perman-Rovsing sign. Eponym A Day. Instagram
- Eponymythology: Appendicitis eponymous signs. LITFL
the names behind the name