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107
spontaneous reversal. Finally in these cases the immediate cause for the disease of the ileum
can be seen from the X-ray. In volvulus, one can see the constriction furrows at the twisted
base of the loop and one can draw a conclusion as to whether the volvulus is of the left-hand
or right-hand form based on whether the shorter leg of the sling and point of torsion are on
the right or left side [103, p.1547–1548].
Thus, Hintze sign refers to the presence of gas and liquid-lled distended loop of
strangulated small bowel.
4.2.25 Burgess Sign
Arthur Henry Burgess (1874–1948) was born in Manchester, UK, and received his
Master of Science in 1895 and Bachelor of Medicine and Bachelor of Surgery
degrees from the Manchester Medical School in 1896 [104–107]. He was elected
fellow of the Royal College of Surgery in 1899, house surgeon to Manchester
Children’s Hospital, Pendlebury, in 1897, and Resident Surgical Ofce (RSO) to the
Manchester Royal Inrmary (MRI) in 1900 [104, 107]. His other appointments
included visiting surgeon at the Manchester Union Hospital, Crumpsall, and a surgi-
cal ofcer at Christie Cancer Hospital [106]. At MRI, he was appointed honorary
assistant surgeon in 1905, full surgeon in 1910, and consulting surgeon in 1934
[106]. During World War I, from 1914 to 1918, he was in charge of the Ofcer’s
Ward at the Second Western General Hospital, as consulting surgeon to the
Mesopotamian Expeditionary Force, and later as consulting surgeon and chief of
the surgical division in a General Hospital [104, 106, 107]. At the Victoria University
of Manchester, he was a lecturer in surgery in 1907 and a professor of clinical sur-
gery from 1921 to 1934 [104, 106, 107].
Burgess was elected president of the British Medical Association in 1929 [104,
106, 107]. He was an honorary doctor of Manitoba University in 1930, president of
the Manchester Surgical Society in 1922, the Manchester Medical Society from
1925 to 1926, and the Association of Surgeons in 1933, and vice-president of the
Royal College of Surgeons from 1934 to 1936 [104, 106, 107].
His character as described by Prof. Geoffrey Jefferson, prior house surgeon of
Arthur Burgess:
Burgess’s work was completely sincere; there never was a less evasive man in his or any-
thing else. Industry, sobriety, thoroughness, honesty, are the works that best express him—
indeed he could not always restrain his irritation over the claims made by those whose sense
of artistry caused them to advance statement that were more “required” than exact, who
indulged thus in scientic romanticism. (…) Burgess excelled in another important way—
namely, his encouragement of the younger surgeons, not of one pupil alone but of several
[107, p.1007].
Burgess described a palpatory nding in patients with acute intestinal obstruction
(Table4.1):
4.2 Eponymous Signs
108
Whenever the outline of dilated coils was seen, with the peristaltic wave passing along, one
might be absolutely certain that it was a case of obstruction which had been in existence for
at least several weeks. Sometimes, even when peristalsis was not visible, it was palpable.
By keeping the hand over the abdomen the coil underneath could be felt alternately,
hardening and softening. That condition of palpable peristalsis, again indicated obstruction
of some considerable standing [108, p.556].
Thus, Burgess sign refers to palpable hardening and softening of the coil of the
bowel occurring in intestinal obstruction.
4.2.26 Fèvre Sign
Marcel Paul Luis Edmond Fèvre (1897–1978) was born in Arras, Pas-de-Calais,
France, and after completing an extern and internship trained under the tutelage of
Louis Ombrédanne (1871–1956), pediatric and plastic surgeon, and Marcel Lance
(1874–1960), a pediatric orthopedic surgeon at Hôpital des Enfants Malades
(Hospital for Sick Children), Paris [109, 110], he also completed an internship with
Victor Veau (1871–1949), a pediatric surgeon. Fèvre was appointed hospital sur-
geon in 1933, associate professor in 1939, at the pediatric surgical clinic of the
Faculty of Medicine, Paris, in 1940, Hôpital St. Louis in 1942, and surgeon to the
Hôpital des Enfants Malades in 1949. He was knighted Grand Ofcer of the Legion
of Honor and was a member of the French Academy of Medicine [109, 110].
Fèvre described three signs of intussusception, which include, based on their
order of appearance, painful crises, vomiting, and bloody anal discharge (Table4.1):
The pain is intense, excruciatingly painful, and colicky. (…) There is a sense of painful
pressure when examining the child during the crisis. The rst colic attack begins in a previ-
ously healthy child whereby suddenly he/she begins to cry, clenches their sts, exes their
thighs, and waves their arms and legs—the abdomen contracts, preventing deep palpation.
Then symptoms resolve, and the child is calm, chatters smiles, and plays. Suddenly the pain
reappears with the same characters, a quarter of an hour to an hour, sometimes later after
the previous crisis. The intermittency of these paroxysmal crises remains the major charac-
teristic that should suggest intussusception. The rst vomiting generally accompanies or
follows the rst painful attack. This vomiting may reoccur during subsequent seizures. (…)
Vomiting is less frequent than painful crises: as a rule, a child with intussusception vomits
what he/she consumes. However, the child often refuses the breast or any other food.
Vomiting becomes less and soon disappears. Beware of this period of interruption because,
when vomiting resumes, it occurs late, and is often bilious. The bloody anal discharge
appears after a few hours and afrms the dreaded intussusception. These bloody emissions
can assume different appearances including: traces of brownish blood staining the nappies;
bloody serous uids; bloody mucus; sometimes brownish melaena; exceptional hemor-
rhage of red blood; and, quite often, actual stool but colored dark brown with blood mixed
in it. In short, the character that dominates these bloody emissions is their polymorphism.
However, we often notice that the quantity of blood is not enormous. The smell of these
stools is variable, often bland; a sickening and unpleasant odor indicates that the small
intestine is involved in the intussusception [111, p.176–177].
Thus, Fèvre sign refers to the clinical features of intussusception.
4 Small andLarge Bowel Signs
109
4.2.27 Kantor Sign
John Leonard Kantor (1890–1947) was born in Moscow, Russia, and immigrated to
the United States that same year [112]. He received his medical and doctoral degrees
from the College of Physicians and Surgeons Medical School of Columbia
University (currently Columbia University Vagelos College of Physicians and
Surgeons), NewYork, in 1912. Kantor completed an internship at Mt. Sinai Hospital
and was a clinical assistant in gastroenterology at the Mt. Sinai Dispensary Clinic
[113]. He served during World War I and II in the United States Army Medical
Corps [112]. He was chief of the Vanderbilt Gastroenterology Clinic at Columbia
Presbyterian Hospital from 1919 to 1932, associate professor in medicine in 1924,
and associate clinical professor of medicine since 1939 at Columbia University
College of Physicians and Surgeons [112]. Kantor also held appointments at
Monteore Hospital in NewYork City (gastroenterologist and associate roentgen-
ologist), Beth David Hospital, Sharon Hospital in Connecticut, Will Roger Hospital
in Saranac Lake, NewYork, and National Jewish Hospital [114].
Kantor described the roentgenographic appearance of the ileum in six patients
with Crohn disease (Table 4.1). The most dramatic nding consisted of the
following:
[s]tring sign, a name borrowed from A.W.Crane. This is a thin, slightly irregular shadow
suggesting a cotton string in appearance and extending more or less continuously from the
region of the last visualized loop of ileum through the entire extent of the lling defect and
extending at the ileocecal valve. It represents the attenuated barium lling of the greatly
contracted intestinal lumen [115, p.2018].
He recognized that the “string sign” may be found in other diseases, including
tuberculosis, syphilis, and sarcomas involving the terminal ileum. Thus, Kantor sign
refers to the thin string-like radiographic shadow due to a radiographic lling defect
as occurring in regional ileitis or Chron disease.
4.2.28 Dennis Sign
Clarence Dennis (1909–2005) was born in St. Paul, Minnesota, USA, and received
his medical degree from the Johns Hopkins School of Medicine in 1935 [116, 117].
He completed an internship and residency at the University of Minnesota and a
Ph.D. degree in 1940 under the aegis of Owen Harding Wangensteen (1898–1981)
[116, 118]. He was a member of the faculty of surgery at the University of Minnesota
and ascended to the rank of full professor of surgery and administrative head of
surgery at Minneapolis General Hospital [117, 119].
He was appointed chair in the Department of Surgery at State University of
NewYork (SUNY) Downstate Medical Center, Brooklyn, from 1951 to 1972 and
also served as a surgeon-in-chief at Kings County Hospital Center [116, 118–121].
He was appointed to direct the Division of Technological Applications, previously
4.2 Eponymous Signs
110
named the Medical Device Application Branch, at the National Heart and Lung
Institute in Bethesda, Maryland, from 1972 to 1974 [121]. He joined the surgical
faculty at the SUNY in Stony Brook and the Veterans Administration Hospital in
Northport, NY, from 1975 to 1988 [116–118, 120]. Dennis moved to St. Paul and
was later appointed director of the University of Minnesota’s Cancer Detection
Center from 1991 to 1996 [116, 118, 120, 121].
He is best recognized as the co-inventor of the multiple-screen blood pump oxy-
genator used in heart-lung machines [121]. His name is eponymously associated
with Dennis clamp, used in abdominal surgery [121]. He is the recipient of several
honors and awards, including the Modern Medicine Distinguished Achievement
Award in 1973, the John H.Gibbon Award by the American Society Extracorporeal
Technician in 1974, and the Laufman-Greatbach Prize by the Association for the
Advancement of Medical Instrumentation for his pioneering work in cardiovascular
surgery and devices in 1984. He also received an honorary doctorate from SUNY,
Brooklyn, in 1988 [116, 117]. He was a member of the American College of
Surgeons and the Nations Society for Medical Research, to name a few [116].
In a tribute to Dennis and his character, Gus Tanaka, an intern at SUNY
Downstate, recalled:
After Tanaka was diagnosed with a tuberculous pulmonary effusion, a week after being
selected for the internship, rather than advising him to seek another career path, as Tanaka
feared, “the kindly Dr. Dennis came to my bedside and assured me that I would not be
dropped from the program”, and outlined a program that would assure Tanaka a better
chance of getting a decent night’s rest [121, p.802].
Dennis and Toon described auscultatory ndings in patients with small bowel
obstruction (Table4.1):
Borborygmus. Arrival of more gas and uid with each cramp causes splashing; the pitch of
the sound heard with a stethoscope rises as the bowel wall becomes more tightly stretched
until the characteristic tinkle is heard. Cramps simultaneous with borborygmi at 3 to 10
minute-intervals are almost pathognomonic of small bowel obstruction [122, p.62].
Thus, Dennis sign refers to cramps occurring with borborygmi every 3 to 10 min-
utes in small bowel obstruction.
4.2.29 Hunt Sign
Claude J.Hunt (1890–?) was born in Warren County, Kentucky, and received his
medical degree from the School of Medicine at Kansas University [123]. He com-
pleted an internship at the Kansas City General Hospital and was a house surgeon at
Wesley Hospital, Kansas City, Missouri [123]. He was a surgical assistant with
W.J.Frick, a Kansas City surgeon. He completed postgraduate studies at Washington
University School of Medicine, St. Louis, Harvard Medical School, Boston, and
overseas at the University of Montpelier, France, and the University of Vienna,
Austria [123]. He served as a lieutenant at Oswego Kansas City-based hospital in
France during World War I [124].
4 Small andLarge Bowel Signs
111
He was Chief of the Hunt Surgical Service; chief of surgery at Research Hospital,
Kansas City; surgeon at the Research Clinic, Kansas City General Hospital,
Menorah Hospital, and St. Mary’s Hospital; and faculty at the University of Kansas
Medical School, Kansas City, Missouri [124].
He was elected president of the Jackson County Missouri State Medical Society,
American Goiter Association, and Missouri State Surgical Society and was chair-
man of the Southern Medical Association Surgical Section [123, 125–127]. He was
also an honorary member of the St. Paul Surgical Society, Philadelphia Proctological
Society, and Rocky Mountain Radiological Society [123].
Hunt described the radiographic nding in intestinal obstruction and strangula-
tion (Table4.1):
In simple obstruction the proximal bowel distends, coil by coil, and gradually assumes a
transverse relationship to the long axis of the body, and the valvulae conniventes can be
seen when the obstructed bowel assumes this characteristic stepladder pattern. (…) On the
contrary, if the distended loop of bowl assumes no denite pattern, is found distended in an
irregular manner and is darker than in previous type and if the valvulae conniventes are not
seen or are poorly visible it may be said that the obstruction is one of a strangulated type
[128, p.463].
Thus, Hunt described the X-ray appearance of the bowel in simple obstruction and
during the early stages of intestinal strangulation. In obstruction without strangula-
tion, there are air-uid levels, while in strangulated obstruction, the distended loop
assumes no specic pattern, and the valvulae conniventes are either scarcely or
not seen.
4.2.30 Kinsella Sign
Victor John Kinsella (1900–1983) was born in Sydney, New South Wales, Australia,
and received his medical training at Sydney University, qualifying in 1922 [129].
He was a resident medical ofcer at Prince Alfred Hospital, Sydney, followed by an
appointment as a medical superintendent at Lewisham Hospital, Sydney [129]. He
was an assistant to Sir Hugh Berchmans Devine (1878–1959) in 1926 and com-
pleted postgraduate surgical training in 1929 at the General Hospital in Vienna
under the auspices of Hans Finsterer (1877–1955) [129].
Kinsella was an honorary surgeon at Hornsby Hospital, Sydney, Australia, from
1931 to 1934, followed by an appointment with the same title at St. Vincent’s
Hospital. He earned a fellowship in the Royal College of Surgeons in 1930 and a
medical degree from the University of Sidney in 1950 [129].
Kinsella described in his book titled The Mechanism of Abdominal Pain
(Table4.1):
Morely states that if the pain arises from the jejunum it is felt above the umbilicus. But
Chester Jones also Miller, Abbott and Karr, distended a small balloon at various levels of
the gastro-intestinal tract and found that the pain from all parts of the small intestine was
situated in the umbilical area. Occasionally it is passed through to the back. In one case only
did it deviate appreciably from the midline and pass to the right iliac fossa [130, p.188].
4.2 Eponymous Signs
112
According to Bailey, Kinsella described an observation found in acute small bowel
obstruction:
Pain in the back, usually low in the lumbar region, occurs occasionally. Such pain is caused
by tension on the mesentery occasioned by extreme increase of intraluminar pressure, the
pain usually being associated with strangulated obstruction [131, p.508].
Thus, Kinsella sign refers to lower back pain in patients with acute small bowel
obstruction.
4.2.31 Patel Sign
Manubhai Dahyabhai Patel (1914–1973) was born in Nar town, Kaira district of
Gujarat, India, and received his medical degree from Grant Medical College
Bombay. He served at the Shree Sayaji General Hospital in Baroda, India [132].
We could not locate Manubhai Dahyabhai Patel’s paper where he described the
sign. Hamilton Bailey recommended that the bell of the stethoscope be rmly applied
just below and to the right of the umbilicus and held in this position for up to 5min.
He reported on the auscultatory nding described by Patel (Table4.1) (Fig.4.1):
[i]n paralytic ileus the clinician must expect to hear, no the hissing, turbulent, rumbling
sounds associated with the colic of intestinal obstruction, but an ominous silence, not as
profound as to warrant its frequent description of “death-like”, but a hush, broken only the
“lub, dub” of the patient’s heart-beat transmitted, presumably, to the abdomen via the over-
distended intestinal coils (M.D.Patel), broken also by succession splashes if the patient
moves, and, in all but the last stages of paralytic ileus, broken, too by very occasional, weak
tinkles [132, p.240].
Thus, Patel sign refers to the auscultation of the heartbeat in the abdomen in patients
with paralytic ileus.
4.2.32 Piulachs Sign
Pedro Piulachs Oliva (1908–1976) was born in Barcelona, Spain, and received his
medical degree in Barcelona in 1931. He was awarded the Medicode Guardia Prize
in 1932 [133–135]. He practiced at the medical facilities of Santiago de Compostela
in 1940; Zaragoza, and Barcelona in 1943, the latter as professor of surgical pathol-
ogy at the Faculty of Medicine from 1943 to 1976. He was appointed dean of the
Faculty of Medicine of the Autonomous University of Barcelona [133].
Piulachs served as president of the Spanish Association of Surgeons, the
Mediterranean Surgery Society, the Sarria Association of Biologists, the Catalan
Society of Surgery from 1956 to 1961, and the National Association of Surgery
[133]. He was a member of the Royal Academies of Barcelona and Madrid and the
recipient of the Commendation of Civil Order of Alfonso X of Castile in 1966
[133, 135].
4 Small andLarge Bowel Signs
113
Fig. 4.1 Patel sign (by Ryan Yale)
In addition to his contributions to the sciences, Piulachs was a humanist, philoso-
pher, and poet who wrote under the pen name Jorge Montiel [133, 134]. For the
quality of his contributions, he was awarded the City of Barcelona Prize for Catalan
poetry in 1970 and Virgil Prize by the Catalan Society of Surgery [133].
As to a description of his character:
He systematized a series of surgical interventions and founded the Spanish School of
Surgery. His scientic personality placed Spanish medical science on par with the most
advanced countries. He always stood out for his great common sense, clarity, and excep-
tional work in teaching [136, p.15]. (…) He was a humble and simple man in treatment but
acquired an enormous stature on the chair’s podium or in the triune of the lecturer. With a
sharp, brilliant mentality and words and a tendency for irony and humor, both in private
conversation and public discourse, he possessed extraordinary clarity that made it easy to
understand complex concepts [135, p.31].
A sign or test (Piulachs ank pinch) and syndrome (Piulachs–Hederich syndrome)
have been eponymously named in honor of Piulachs. We were unable to locate
Piulachs’s paper on the ank pitch sign [137]. A description of this sign of appendi-
citis is found in Chap. 5—Appendicitis: Somatic and Visceral Nerve Reexes Signs:
Mechanisms and Pathophysiologic Approach in Acute and Chronic Disease.
4.2 Eponymous Signs
114
Piulachs and Hederich described two cases in which there was acute dilation of
the colon caused by dolicomegacolon (abnormal, elongated, redundant colon)—the
latter is part of a visceral syndrome due to episodic hypersympathonia:
[w]e have observed a type of dynamic occlusion which appears suddenly with enormous
meteorism, without gas emission or evacuation of feces. (…) [t]ype of acute paralytic
dynamic occlusion described as a complication of dolicomegacolon. We consider this com-
plication a homolog in the colon of the dilation of the stomach that complicates the mega-
stomach; that is why we designate it with the name of acute dilation of the colon [138,
p.1702]. In this condition, there is no evidence of mechanical occlusion or vascular injury.
Patients present with intermittent diffuse abdominal pain with dilation of the colon: In acute
colon dilation, meteorism is considerable; it is usually atonic without peristalsis and pre-
dominately supraumbilical. By radiological examination in volvulus, the enormous dilated
loop is observed, which does not admit the opaque enema. In contrast, in acute dilation, a
global colon dilation is observed [138, p.1703].
When a probe is inserted into the colon, gas without liquid is expelled, causing
deation of the abdomen and immediate symptomatic relief. Thus Piulachs sign
refers to acute colon dilation occurring in patients with a congenital deformity
marked by being elongated and redundant (dolicomegacolon). This nding presum-
ably represents the condition referred to as acute intestinal pseudo-obstruction.
4 Small andLarge Bowel Signs
115
Table 4.1 Small and large bowel signs
Name Year Description of sign Signicance
Dance [7] 1826 The cecum and the colon are displaced to the left side of the abdomen and are now located at the
sigmoid exure. The absence of the ascending colon and cecum causes a depression on the right
side of the abdomen. A longitudinal enlarged voluminous mass is present on the left side of the
abdomen
Intussusception
Cruveilhier [12] 1849 There are two characteristic signs of strangulation caused by intussusception: swelling and
hematochezia
Intussusception
Blatin [14] 1877 The abdomen is distended without uctuation. Percussion caused the abdomen to move and
tremble, similar to a gelatinous mass
Intestinal obstruction
Cherchevsky [16] 1883 The episodes occurred unexpectedly. From disease onset, the volume or stool’s diameter was
noticeably smaller. Usually, the stool frequency increases four or ve days before the spell. Instead
of just one a day, there were two or even three bowel movements, with the feces usually molded
into the shape of a sausage. The feces thinned out even more and eventually broke off into distinct,
rounded pieces ranging from the size of a walnut to that of a hazelnut—this form degenerated into
ribbons somewhat thicker toward the middle and attened toward the edges. Later the evacuations
were only the thickness of a pencil, after which they became quite liquid and were expelled in the
form of a very thin jet. Simultaneously with this nal form, there was a painful sensation under the
costal margins and the pains described above, signifying the beginning of the attack. These
gradually changes in the form and consistency of the stools preceded the severe crises.
Simultaneously with the onset of pain under the false ribs, the patient’s face becomes pale and
slightly cyanotic, breathing accelerated to 26-28 bpm; the transverse diameter of the heart slightly
exceeds the left parasternal line; the heartbeat slowed with the pulse decreasing from 70 to 60. The
upper part of the abdomen is distended. Percussion makes a sonorous and tympanic noise heard
with a metallic undertone. At the onset of the attack, the bloating, in most cases, is circumscribed,
sometimes occurring in the epigastrium, while at other times, at the right or left colon exures
Irritable bowel
syndrome (mixed
variant)
Wahl [23] 1886 The darker color, increased gaseous dilation, and congestion of the portion of the intestine above
the obstruction lead to the point of constriction
Strangulating bowel
obstruction
(continued)
4.2 Eponymous Signs
116
Table 4.1 (continued)
Name Year Description of sign Signicance
Hirschsprung [28] 1888 Dilation and thickening of the walls, especially the muscularis, of the large intestines with a
normal- appearing rectum. The mucosa in dilated segments has considerable erosions and
ulcerations, which vary signicantly in size and depth. The nger could easily be inserted into the
rectum which was often full of feces on exploration
Dilation and
hypertrophy of the
distal colon
Gangolphe [34] 1893 Constriction of the intestinal loop results in a sero-bloody liquid in the peritoneal cavity and
intestines. The quantity of uid is proportional to the extent of the trapped intestinal loop and the
intensity of the constriction
Strangulated bowel
obstruction
Schlange [37] 1894 With intestinal obstruction, the efferent portion of the intestine is always empty and collapses, while
the afferent portion is dilated. In the absence of peritonitis, peristaltic movements occur in the
dilated intestine. The movements are strongest where obstruction develops slowly (e.g., a slowly
growing mass with strictures) because here, the muscularis of the proximal intestine has time to
hypertrophy
Intestinal obstruction
Mya [43] 1894 On inspection, two furrows are observed from top to bottom and from right to left. One is located
1cm below the umbilicus in the midline, the other 6cm above it. These two sulci circumscribe an
enormous intestinal loop. Above the superior sulcus, there is a second tubular protrusion directed
transversally. The median loop measured between the two grooves is 11cm. The upper loop
measures 6cm
Dilation and
hypertrophy of the
distal colon
Gersuny [47] 1896 The intestinal mucosa adheres to the viscous collection of feces, forming a mass when the nger is
pressed intensively and detaches itself again when the pressure is released
Dilation and
hypertrophy of the
distal colon
Bayer [50] 1898 The patient’s abdomen shifts to the left in the upper and right in the lower half, forming an
S-shaped bead. An oblique bulge runs diagonally from the top left to the bottom right, bending to
the left again in the right hypogastrium and extending to the bottom right in the cecal region. It is
stretched to the point of bursting and was hemispherically round, “like a bent knee.” The saddle-
shaped indentation was found on the left at the border between the epigastrium and hypogastrium.
The largest protrusion usually occurs with pronounced colon meteorism, which conforms to the
same protrusion in the opposite abdominal region
Sigmoid volvulus
4 Small andLarge Bowel Signs