Sherren triangle

Description

Area of skin hyperaesthesia bounded by lines joining anterior superior iliac spine, the pubic symphysis and umbilicus. One of myriad signs associated with acute appendicitis.

History of the Sherren triangle

1893 – Sir Henry Head (1861-1940) first drew attention a to the subject of cutaneous hyperalgesia in visceral. No special attention is paid to its occurrence in appendicitis, but Head mentions that in:

…affections of the intestine down to the upper part of the rectum superficial tenderness may appear in the ninth, tenth, and eleventh dorsal segmental areas.’

Head 1893

1902 – RF Müller read a paper at the Freie Vereinigung der Chirurgen Berlin on Head’s Areas in Surgical Abdominal Disease. He mentions that he has:

…found hyperalgesia in early cases of appendicitis with tolerable frequency, this hyperalgesia usually appearing in the neighbourhood of McBurney’s point.

Müller 1903

1903 – James Sherren (1872-1945) examined 51 consecutive cases of appendicitis to evaluate deep versus cutaneous signs of the disease process

Cutaneous hyperalgesia is tested by gently pinching or stroking the skin, beginning if possible in an area which is not tender and working towards the suspected tender area and so marking out its boundaries.

In appendicitis cutaneous hyperalgesia varies from a complete band extending on the right side from the middle line below the umbilicus in front to the lumbar spines behind, down to a small circular spot a little above the middle point between the umbilicus and the anterior superior spine.

As an aid in determining operation the disappearance of hyperalgesia is of the utmost importance. If well-marked superficial tenderness disappears without coincident amelioration of the general condition of the patient it is a sign of perforation or gangrene of the appendix.

Sherren 1903

1905 – Sherren further defines the ‘appendix triangle’ to assist in decision for operative intervention in regards to appendix abscess. Sherren describes the area of superficial hyperalgesia as

…a triangular area on the right side of the abdomen, which I described as ‘the appendix triangle’, bounded below by Poupart’s ligament, above by a line drawn out from the umbilicus, and to the inner side by a vertical line just to the right of the mid-line. Its apex is at the anterior superior spine

Sherren 1905

Associated Persons

• Sir Henry Head (1861-1940)
• James Sherren (1872-1945)

References

Original articles

• Head H. On disturbances of sensation with especial reference to the pain of visceral disease. Brain. 1893; 16(1-2): 1-133
• Sherren J. On the occurrence and significance of cutaneous hyperalgesia in appendicitis. Lancet 1903; 162(4177): 816-821
• Sherren J. The causation and treatment of Appendicitis. Practitioner, 1905; 74: 833-844

Review articles

• Müller. Head’schen Zonen. Zentralblatt für Chirurgie. 1903; 30(2): 54
• Mackenzie J. The nature of the symptoms in appendicitis. Br Med J 1903; 2: 66
• Eponymythology: Appendicitis eponymous signs. LITFL

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