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117
Name Year Description of sign Signicance
Bouveret [55] 1899 Observe the patient’s abdomen as he/she complains of colic. A strong, globular swelling lifts the
abdominal wall in the right iliac fossa, epigastrium, and umbilicus. In contrast, the hypochondrium
and left iliac fossa remain soft and depressible and maintain their normal conguration. During the
painful crisis, an oblique line may be found extending from the middle of the right femoral arch to
the left costal margin, dividing the abdomen into two parts: the right colon, with strong peristaltic
contractions, and the left colon, without these strong peristaltic contractions. Later, if the
obstruction is complete, it may also involve the small intestine. At that time, the sign no longer has
the same value. However, generalized abdominal peristalsis starts and sometimes remains localized
to the right side
Transverse colon
obstruction
Anschütz
a
[60] 1902 Local gaseous dilation is observed in patients with cecal obstruction and a closed ileocecal valve Colon obstruction
Nothnagel [66] 1905 (1) Ileal succession splash: In intestinal stenosis, there is frequently a feeling of uctuation on
palpation, and occasionally a distinct succussion sounds heard proximal to the stenosis
(2) Early in distal colonic obstruction, only the large intestine is distended, with dilation present at
the anks: In stenosis of the sigmoid exure complicated by gaseous dilation from stasis, the upper
and lateral aspects of the abdomen are usually distended. The distension of the lateral aspect of the
abdomen is generally called ank meteorism. Flank gaseous distension may be unilateral when the
bowel distension is limited to certain colon sections. This may occur even when stenosis is in the
sigmoid exure, for only a short segment of the bowel above the stricture may be distended
(3) Percussion sound is located over the same site as the ileus: In cases of bowel stenosis, no
denite and reliable information is gained by percussion. There is only one point of diagnostic
importance: when local gaseous distension is limited to a circumscribed area of the bowel, which
can be identied by percussion. Whenever this condition is found, efforts should be directed toward
identifying other signs of bowel constriction in this area. Localized tympanites is of value only in
the diagnosis of narrowing of the bowel when combined with other symptoms
Bowel obstruction
Lane [74] 1910 A new band forms beneath the last few inches of the mesentery of the small intestines. This band is
initially part of the undersurface of the mesentery. Later it forms a ligament distinct from the
mesentery. The ligament contracts and deforms the ileum, producing a kink or obstruction,
particularly in the erect posture. Because of this kink, the small intestines dilate, potentially
extending up to the pylorus
Small bowel
obstruction
(continued)
4.2 Eponymous Signs
118
Table 4.1 (continued)
Name Year Description of sign Signicance
Stierlin [77] 1911 An inltrative, indurated, and ulcerative processes of the cecum and ascending colon
radiographically identied after 5 to 6 hours by the absence of a physiological shadow in this colon
section. Cecal tuberculosis is, therefore, the absence of the cecum and ascending colon shadows
between the lower ileum and transverse colon. Radiographically, ulcerations and inltrates are seen
in the remainder of the colon by a gap corresponding to the diseased section
Cecal tuberculosis
Cole [82] 1914 A deformity of the cap or sphincter is present and caused by the surrounding induration and
cicatricial contraction of an ulcer crater. The induration within an ulcer projects into the cap’s
lumen, causing a displacement of contrast. It may be so small as to present only a constant dent on
the side of the cap, or it may be extensive as to distort the lumen of the cap. Alternatively, the
process may involve one-half of the cap without distorting the other half
Duodenal ulcers
Mathieu [86] 1914 (1) Intestinal uid and stasis accumulate proximal to an area of stenosis are demonstrated by
extensive clapotage (splashing sound) and percussion dullness
(2) Method for distinguishing uid within the stomach from the intestines: It may be difcult to
distinguish intestinal obstruction from gastric dilatation due to pyloric stenosis. The stomach is dull,
only in the left decubitus position. In contrast, in the right lateral decubitus position, dullness
caused by uid within the stomach follows a convex line at the bottom, stopping slightly below the
umbilicus. Intestinal sounds are present below this area
Intestinal obstruction
Butters [87] 1915 Subtle, shiftable palpable resistance under the right costal arch in the parasternal line and occult
blood suggests right (hepatic) exural carcinoma
Colon cancer at the
right exure
Kloiber [90] 1919 Gas and liquid are found on a standing uoroscopy or X-ray separated by a horizontal line. The
number of air-uid levels varies depending on the location of the disease and the duration of the
incarceration. Several air-uid levels near the stomach suggest a more proximal obstruction, while
numerous uid levels in the pelvis indicate more distal small bowel obstruction
Small bowel
obstruction
Hedri [91] 1920 Excision of an epiploic appendage at its base causes arterial bleeding Colon viability
Gold [95] 1924 Palpation of the small intestines during the rectal examination requires an increase and abnormal
composition of the intestinal contents that liquefy and accumulate, proximal to the small bowel
obstruction, leading to widening of the intestinal loops and early hypertrophy of the muscular
intestinal wall, and an abnormal loop of the prestenotic portion of the small bowel
Small bowel
obstruction
4 Small andLarge Bowel Signs
119
Name Year Description of sign Signicance
Fleischner [100] 1928 The opening of the ileocecal valve is patent. Rotate the patient or apply pressure to bring the area
into view in order to avoid an overlying cecal shadow
Insufciency of the
ileocecal valve
Hintze [103] 1928 Small intestinal loops show the typical Kerckring folds (valvular conniventes) and large intestinal
loops shows haustral marking
Bowel obstruction
Burgess [108] 1929 Obstruction present for at least several weeks is signied by observing an outline of dilated coils of
the intestines seen with the peristaltic wave. 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
Intestinal obstruction
Fèvre [111] 1930 The pain is intense, excruciatingly, and colicky. One senses that the child is experiencing painful
pressure on examination during the crisis. The rst colic attack begins suddenly. The child cries,
clenches his hands and thighs and waves his arms and legs—the abdomen contracts, preventing
deep palpation. Then symptoms resolve, and the child is now calm, chatters, smiles, and plays.
Suddenly the pain reappears a quarter of an hour, an hour, sometimes later after the previous crisis
with the same character. The intermittency of these paroxysmal crises is the primary characteristic
suggesting intussusception. Initial vomiting generally accompanies or follows the rst painful
attack. This vomiting may reoccur during subsequent episodes. Vomiting is less frequent than
painful crises: as a rule, a child with intussusception vomits what he/she eats. However, the child
often refuses to eat. Vomiting occurs less frequently and then resolves. Beware of this period of
interruption because, when vomiting resumes, it occurs later and is often bilious. The bloody
emission from the anus appears after a few hours and afrms intussusception. These bloody
emissions contain traces of brownish blood staining the nappies, bloody serous uids, bloody
mucus, sometimes brownish melaena, hemorrhage of red blood, and, quite often, actual stool, but
colored brown, dark with blood mixed with it. In short, the character that dominates these bloody
emissions is their different forms. However, often the quantity of blood is not enormous. The smell
of these stools is variable, often bland; sickening and unpleasant odors indicate the small intestine’s
participation in the intussusception
Intussusception
Kantor [115] 1934 The “string sign” is a thin, slightly irregular shadow extending continuously from the region of the
last visualized loop of ileum through the entire extent of the lling defect to the ileocecal valve
Ileal stenosis
(continued)
4.2 Eponymous Signs
120
Table 4.1 (continued)
Name Year Description of sign Signicance
Dennis [122] 1946 The arrival of more gas and uid with each cramp causes splashing. The pitch of the sound
auscultated with a stethoscope rises as the bowel wall becomes more tightly stretched until the
characteristic tinkle is heard. Cramps occur simultaneously with borborygmi at 3- to 10-min
intervals
Small bowel
obstruction
Hunt [128] 1948 In simple obstruction the proximal bowel distends, coil by coil, and gradually assumes a transverse
relationship to the long axis of the body. The valvulae conniventes can be seen. The obstructed
bowel assumes this characteristic stepladder pattern. In strangulated type of obstruction the
distended loop of bowl assumes no denite pattern, is found distended in an irregular manner, is
darker than in previously, and if the valvulae conniventes are not seen or are poorly visible
Intestinal obstruction
and strangulation
Kinsella [130] 1948 Pain from all parts of the small intestine is usually situated in the umbilical area, and occasionally
referred to the back in the lower lumbar region
Small bowel
obstruction
Patel [132] 1973 The bell of the stethoscope is rmly applied just below and to the right of the umbilicus and held in
this position for up to 5min. In paralytic ileus, the abdomen is silent. Only the “lub, dub” of the
patient’s heartbeat transmitted, presumably, to the abdomen via the overdistended intestinal coils
broken by succession splashes if the patient moves
Paralytic ileus
Piulachs [138] [n.a.] Acute paralytic dynamic occlusion appears suddenly with enormous meteorism, without gas
emission or evacuation of feces as a complication of dolicomegacolon. Patients present with
intermittent diffuse abdominal pain with dilation of the colon. In acute dilation of the colon,
meteorism is considerable; it is usually atonic without peristalsis and predominately located
supraumbilical
Acute colon dilation
a
Denotes an individual who supported anti-semitism, racial acts, or committed crimes against humanity
4 Small andLarge Bowel Signs
121
4.3 Conclusion
Signs of the small and large intestines were identied through observation, palpa-
tion, and auscultation. Many of these signs are unknown and not recognized by
those whose discovery was rst published. They provide the reader with a more
in- depth appreciation of the physical examination skills employed by these physi-
cians as a method of diagnosis.
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