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A sign is an indication of some fact or quality; and a medical sign is an objective indication of some medical fact or quality that is detected by a physician during a physical examination of a patient.
There is a strong implication that the signs have no meaning for a patient, and may not even be noticed by them; yet they are full of meaning for the physician, and are often significant in assisting a physician to identify the disease(s) responsible for the patient's symptoms.
The term sign is not to be confused with the term indication, which denotes a valid reason for using some treatment.
Signs and semiotics
The art of interpreting clinical signs was originally called semiotics in English. This term, then spelt semeiotics (derived from the Greek adjective σημειοτικός: semeiotikos, "to do with signs"), was first used in English in 1670 by Henry Stubbes (1631-1676), to denote the branch of medical science relating to the interpretation of signs:
- …nor is there any thing to be relied upon in Physick, but an exact knowledge of medicinal phisiology (founded on observation, not principles), semeiotics, method of curing, and tried (not excogitated, not commanding) medicines…
Signs versus symptoms
For convenience, signs are commonly distinguished from symptoms as follows: a symptom is something abnormal, that is relevant to disease, experienced by a patient, whilst a sign is something abnormal, that is relevant to disease, discovered by the physician during his examination of the patient:
- …a sign is an objective symptom of a disease; a symptom is a subjective sign of disease.
According to King, it is an essential feature of a sign that there is both a sign and a thing signified. And, because "the essence of a sign is to convey information", it can only be a sign if it has meaning. Therefore, "a sign ceases to be a sign when you cannot read it".
A slightly different definition views signs as any indication of a disease that can be objectively observed (i.e. by someone who isn't the patient), whereas a symptom is merely any manifestation of a disease that is apparent to the patient (i.e. reasons why diseases are bad). From this definition, it can be said that an asymptomatic patient is uninhibited by disease. With this set of definitions, there is some overlap--certain things may qualify as both a sign and a symptom (e.g. a bloody nose).
Types of signs
Medical signs may be classified by the type of inference that may be made from their presence, for example:
- Prognostic signs (from progignṓskein, προγιγνώσκειν, "to know beforehand"): signs that indicate the outcome of the current bodily state of the patient (i.e., rather than indicating the name of the disease). Prognostic signs always point to the future. Perhaps the most famous prognostic sign is the facies Hippocratica.
|“||"[If the patient's facial] appearance may be described thus: the nose sharp, the eyes sunken, the temples fallen in, the ears cold and drawn in and their lobes distorted, the skin of the face hard, stretched and dry, and the colour of the face pale or dusky.… and if there is no improvement within [a prescribed period of time], it must be realized that this sign portends death."||”|
- Anamnestic signs (from anamnēstikós, ἀναμνηστικός, "able to recall to mind"): signs that (taking into account the current state of a patient's body), indicate the past existence of a certain disease or condition. Anamnestic signs always point to the past. (Whenever we see a man walking with a particular gait, with one arm paralysed in a particular way, we say “This man has had a stroke”; and, if we see a woman in her late 50s with one arm distorted in a particular way, we say “She had polio as a child”.)
- Diagnostic signs (from diagnōstikós, διαγνωστικός, "able to distinguish"): signs that lead to the recognition and identification of a disease (i.e., they indicate the name of the disease).
- Pathognomonic signs (from pathognomonikós, παθογνωμονικός, "skilled in diagnosis", derived from páthos, πάθος, "suffering, disease", and gnṓmon, γνώμον, "judge, indicator"): the particular signs whose presence means, beyond any doubt, that a particular disease is present. They represent a marked intensification of a diagnostic sign. (An example would be the palmar xanthomata seen on the hands of people suffering from hyperlipoproteinaemia.) Singular pathognonomic signs are relatively uncommon.
|“||[Thus] a symptom is a phenomenon, caused by an illness and observable directly in experience. We may speak of it as a manifestation of illness. When the observer reflects on that phenomenon and uses it as a base for further inferences, then that symptom is transformed into a sign. As a sign it points beyond itself — perhaps to the present illness, or to the past or to the future. That to which a sign points is part of its meaning, which may be rich and complex, or scanty, or any gradation in between. In medicine, then, a sign is thus a phenomenon from which we may get a message, a message that tells us something about the patient or the disease. A phenomenon or observation that does not convey a message is not a sign. The distinction between signs and symptom rests on the meaning, and this is not perceived but inferred.||”|
Technological development creating signs detectable only by physicians
Prior to the nineteenth century there was little difference between physician and patient. Most medical practice was conducted as a joint co-operative interaction between the physician and the patient as equals. Whilst each noticed much the same things, the physician had a more informed interpretation of those things: “the physicians knew what the findings meant and the layman did not”.
Advances in the 19th century
- the 1808 introduction of the percussion technique:
|“||"The process through which “the physician can assess the state of the underlying lung by sensing the character of vibrations by gentle taps on the chest wall […something which…] greatly facilitated the diagnosis of pneumonia and other respiratory diseases” ||”|
The techniques, which had been first described by the Viennese physician Leopold Auenbrugger (1722-1809) in 1761, became far more widely known following the publication of Corvisart’s translation of Auenbrugger's work in 1808.
- the 1819 introduction of the technique of auscultation following the 1819 publication of René Théophile Hyacinthe Laënnec's (1781-1826) findings on the use of his modified stethoscope. (He had invented a very crude form of stethoscope in 1816; but it was his subsequent modification of that later stethoscope that was the subject of his 1819 publication. Laënnec's 1819 publication was Forbes translated into English in four editions between 1821 and 1834 by Sir John Forbes.)
- The 1846 introduction by surgeon John Hutchinson (1811-1861) of the spirometer, an apparatus for assessing the mechanical properties of the lungs per medium of measurements of forced exhalation and forced inhalation. (The recorded lung volumes and air flow rates are used to distinguish between restrictive disease (in which the lung volumes are decreased: e.g., cystic fibrosis) and obstructive diseases (in which the lung volume is normal but the air flow rate is impeded; e.g., emphysema).)
- The 1851 invention, by Hermann von Helmholtz (1821-1894), of the opthalmoscope, which allowed physicians to examine the inside of the human eye.
- the 1895 clinical use of X-rays which began almost immediately after they had been discovered that year by the German Wilhelm Conrad Röntgen (1845-1923).
- the 1896 introduction of the sphygmomanometer, designed by Italian Scipione Riva-Rocci (1863-1937), to measure blood pressure.
Alteration of the relationship between physician and patient
The introduction of the techniques of percussion and auscultation into medical practice immediately altered the relationship between physician and patient in a very significant way, specifically because these techniques relied almost entirely upon the physician listening. (King observes that the introduction of the stethoscope did not immediately revolutionize medicine; because, although the physicians could certainly hear some thing via these techniques, they had no idea whatsoever of what those particular sounds, in those particular rhythms, in those particular combinations actually meant. In other words, although they certainly were being bombarded with noises, they were noises that signified nothing at all.)
Not only did this greatly reduce the patient's capacity to observe and contribute to the process of diagnosis, it also meant that the patient was often instructed to stop talking, and remain silent.
As these sorts of evolutionary changes continued to take place in medical practice, it was increasingly necessary to uniquely identify data that was accessible only to the physician, and to be able to differentiate those observations from others that were also available to the patient, and it just seemed natural to use "signs" for the class of physician-specific data, and "symptoms" for the class of observations available to the patient.
King proposes a more advanced notion; namely, that a sign is something that has meaning, regardless of whether it is observed by the physician or reported by the patient:
- The belief that a symptom is a subjective report of the patient, while a sign is something that the physician elicits, is a 20th-century product that contravenes the usage of two thousand years of medicine. In practice, now as always, the physician makes his judgments from the information that he gathers. The modern usage of signs and symptoms emphasizes merely the source of the information, which is not really too important. Far more important is the use that the information serves. If the data, however derived, lead to some inferences and go beyond themselves, those data are signs. If, however, the data remain as mere observations without interpretation, they are symptoms, regardless of their source. Symptoms become signs when they lead to an interpretation. The distinction between information and inference underlies all medical thinking and should be preserved.
Signs as tests
In some senses, the process of diagnosis is always a matter of assessing the likelihood that a given condition is present in the patient. In a patient who presents with haemoptysis (coughing up blood), the haemoptysis is very much more likely to be caused by respiratory disease than by the patient having broken their toe. Each question in the history taking allows the medical practitioner to narrow down their view of the cause of the symptom, testing and building up their hypotheses as they go along.
Examination, which is essentially looking for clinical signs, allows the medical practitioner to see if there is evidence in the patient's body to support their hypotheses about the disease that might be present.
A patient who has given a good story to support a diagnosis of tuberculosis might be found, on examination, to show signs that lead the practitioner away from that diagnosis and more towards sarcoidosis, for example. Examination for signs tests the practitioner's hypotheses, and each time a sign is found that supports a given diagnosis, that diagnosis becomes more likely.
Special tests (blood tests, radiology, scans, a biopsy, etc.) also allow a hypothesis to be tested. These special tests are also said to show signs in a clinical sense. Again, a test can be considered pathognonomic for a given disease, but in that case the test is generally said to be "diagnostic" of that disease rather than pathognonomic. An example would be a history of a fall from a height, followed by a lot of pain in the leg. The signs (a swollen, tender, distorted lower leg) are only very strongly suggestive of a fracture; it might not actually be broken, and even if it is, the particular kind of fracture and its degree of dislocation need to be known, so the practitioner orders an x-ray. The x-ray film shows a fractured tibia, so the film is said to be diagnostic of the fracture.
Examples of signs
- ↑ http://www.emedicine.com/asp/dictionary.asp?keyword=sign
- ↑ Definition at University of Western Ontario
- ↑ Stubbe, H. (Henry Stubbes), The Plus Ultra reduced to a Non Plus: Or, A Specimen of some Animadversions upon the Plus Ultra of Mr. Glanvill, wherein sundry Errors of some Virtuosi are discovered, the Credit of the Aristotelians in part Re-advanced; and Enquiries made...., (London), 1670, p.75
- ↑ See list of eponymous medical signs, and "Who Named It?"  for more information on eponymous signs.
- ↑ King, Lester S. (1982). Medical thinking: a historical preface. Princeton, N.J: Princeton University Press. ISBN 0691082979. , p.75.
- ↑ King (1982), pp.73-74.
- ↑ King (1982), pp.80-81
- ↑ Chadwick, J. & Mann, W.N.(trans.) (1978). Hippocratic writings. Harmondsworth [Eng.]: Penguin, 170-171. ISBN 0-14-044451-3.
- ↑ King, 1982, p.81
- ↑ 10.0 10.1 Jewson, N.D., "Medical Knowledge and the Patronage System in 18th Century England", Sociology, Vol.8, No.3, (1974), pp.369-385.
- ↑ 11.0 11.1 Jewson, N.D., "The Disappearance of the Sick Man from Medical Cosmology, 1770-1870", Sociology, Vol.10, No.2, (1976), pp.225-244.
- ↑ King (1982), p.82.
- ↑ Tsouyopoulos N (1988). "The mind-body problem in medicine (the crisis of medical anthropology and its historical preconditions)". Hist Philos Life Sci 10 Suppl: 55–74. PMID 3413276.
- ↑ Weatherall, D.. Science and the Quiet Art: The Role of Medical Research in Health Care. New York: W. W. Norton & Company, 46. ISBN 0-393-31564-9.
- ↑ King (1982, p.83)
- ↑ King (1982), p.89.
- Who Named It?: eponymous signs.
Symptoms and signs: respiratory system (R04–R07, 786)
|; Respiratory sounds:
|Chest, general||* Chest pain|
Symptoms and signs: digestive system and abdomen (R10–R19, 787,789)
|Abdominal – general|
Symptoms and signs: skin and subcutaneous tissue (R20-R23, 782)
|Disturbances of skin sensation||Hypoesthesia - Paresthesia - Hyperesthesia|
|Other||Rash - Cyanosis - Pallor - Flushing - Petechia - Desquamation - Induration - Diaphoresis|
Symptoms and signs: nervous and musculoskeletal systems (R25-R29, 781)
|Abnormal involuntary movements|
(see also movement disorders)
|Tremor - Spasm - Fasciculation - Athetosis|
|Gait abnormality||Scissor gait - Antalgic gait - Cerebellar ataxia - Festinating gait - Pigeon gait - Propulsive gait - Steppage gait - Stomping gait - Spastic gait - Myopathic gait - Magnetic gait - Trendelenburg gait|
|Lack of coordination||Ataxia (Cerebellar ataxia, Sensory ataxia) - Dysmetria - Dysdiadochokinesia - Hypotonia|
|Other||Tetany - Meningism - Hyperreflexia - Opisthotonus - Abnormal posturing - Hemispatial neglect|
Symptoms and signs: urinary system (R30-R39, 788)
|General||Renal colic - Dysuria - Vesical tenesmus - Urinary incontinence - Urinary retention - Oliguria - Polyuria - Nocturia - Extravasation of urine - Extrarenal uremia|
Symptoms and signs: cognition, perception, emotional state and behaviour (R40-R46, 780-781)
|General||Anxiety - Somnolence - Coma - Amnesia (Anterograde amnesia, Retrograde amnesia) - Dizziness/Vertigo|
|Olfaction||Anosmia - Parosmia|
|Taste||Ageusia - Parageusia|
Symptoms and signs: Speech and voice (R47-R49, 784)
|Aphasia/Dysphasia||Expressive aphasia - Receptive aphasia - Conduction aphasia|
|Other speech disturbances||Dysarthria - Schizophasia|
|Symbolic dysfunctions||Dyslexia - Alexia - Agnosia (Prosopagnosia) - Apraxia - Acalculia - Agraphia|
|Voice disturbances||Dysphonia - Aphonia|
Symptoms and signs: general (R50-R69, 780-789)
|General||Fever (Hyperpyrexia) - Headache - Chronic pain - Malaise/Fatigue (Asthenia, Debility) - Fainting (Vasovagal syncope) - Febrile seizure - Shock (Cardiogenic shock) - Lymphadenopathy - Edema (Peripheral edema, Anasarca) - Hyperhidrosis (Sleep hyperhidrosis) - Delayed milestone - Failure to thrive - Short stature (Idiopathic) - food and fluid intake (Anorexia, Polydipsia, Polyphagia) - Cachexia - Xerostomia - Clubbing - Tenderness|
Symptoms and signs: Symptoms concerning nutrition, metabolism and development (R62–R64, 783)
|Growth||Delayed milestone • Failure to thrive • Short stature (e.g., Idiopathic)|
Eponymous medical signs
|Obstetrics||Abderhalden reaction - Braxton Hicks contraction - Chadwick sign - Goodell's sign|
|Neurology||Holmes-Adie syndrome - Argyll Robertson pupils - Babinski sign - Brudzinski sign - Cushing's triad - Froment's sign - Gowers' sign - Hoffman's sign - Jendrassik maneuver - Lasègue's sign - Lhermitte's sign - Marcus Gunn pupil - Myerson's sign - Terry's nails - Tinel's sign - Todd's paresis - Trendelenburg gait - Uhthoff's phenomenon - Unterberger test - Wada test|
|Other||Aaron sign - Abadie's sign - Abadie's symptom - Abelin reaction - Abel's test - Adson's sign - Alexander's law - Allen's test - Apley grind test - Arneth count - Aschoff body - Auer rods - Auspitz's sign - Austin Flint murmur - Baghdad boil - Bainbridge reflex - Bairnsdale ulcer - Battle's sign - Beau's lines - Beck's triad - Beevor's sign - Bence Jones protein - Benedict solution - Still's murmur - Biot's respiration - Bitot's spots - Blumberg sign - Boas' sign - Boston's sign - Bouchard's nodes - Bracht-Wachter bodies - Brushfield spots - Cabot rings - Caput medusae - Cardarelli's sign - Chaddock reflex - Charcot-Leyden crystals - Charcot's triad - Cheyne-Stokes respiration - Chvostek's sign - Schamroth's window test - Codman's triangle - Coombs test - Corrigan pulse - Councilman body - Courvoisier's law - Crowe sign - Cullen's sign - Curschmann spirals - Darier's sign - De Musset's sign - Gottron's papules - Döhle bodies - Duroziez's sign - Epstein's pearls - Ewart's sign - Broca aphasia - Finkelstein's test - Fordyce spots - Fothergill's sign - Friedreich's sign - Goodsall's rule - Grey Turner's sign - Hamman's sign - Hampton's hump - Harrison's groove - Heberden's node - Hegar's sign - Hill's sign - Hippocratic face - facies Hippocratica - Hippocratic fingers - Hirschberg test - Hollenhorst plaque - Adie pupil - Homan's sign - Hutchinson's teeth - Celsus signs of inflammation - Janeway lesion - Kayser-Fleischer ring - Kehr's sign - Kerley lines - Koebner's phenomenon - Koplik's spots - Korotkoff sounds - Kussmaul breathing - Kussmaul's sign - Lachman maneuver - Leser-Trelat sign - Levine's sign - Lisch nodule - Lisker's sign - Macewen's sign - McBurney's sign - McMurray test - Mees' lines - Mentzer index - Mulder's sign - Müller's maneuver - Müller's sign - Murphy's punch sign - Murphy's sign - Nardi test - Nelson's syndrome - Nikolsky's sign - Ladin's sign - Oliver's sign - Osler's node - Osler's sign - Patrick's test - Pemberton's sign - Phalen's maneuver - Plummer-Vinson syndrome - Queckenstedt's maneuver - Quincke's sign - Reynolds' pentad - Rigler's sign - Rinne test - Romana's sign - Romberg test - Rovsing's sign - Russell's sign - Schilling test - Schirmer's test - Schober test - Siegrist streaks - Sister Mary Joseph sign - Stroop test - Susac's syndrome - Tolosa-Hunt syndrome - Traube's sign - Trendelenburg's sign - Trousseau's sign - O'Donoghue's triad - Virchow-Robin spaces - Virchow's triad - Volkmann's contracture - Von Graefe sign - Graefe's sign - Waddell's signs - Watson's water hammer pulse - Whipple's triad - Widal test - Winterbottom's sign|
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