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238
This type of growth belongs to the group of those under the name of scirrhus. I believe we
ought to designate it with the name of cirrhosis, because of its color. Its common causes of
ascites, and has the peculiarity that as the cirrhosis develops, the tissue of the liver is
absorbed, and it ends often, as in the subject, by disappearing entirely; and that in all the
cases, a liver which has cirrhosis becomes smaller in volume instead of increasing all the
more. This type of growth develops also in other organs, and nishes by softening like all
morbid growths [6, p.196].
The earliest known account of gallstones was by Alexander of Tralles (c. 525–c.
605), a respected physician in the Byzantine Empire. Gentile da Foligno (d. 1348)
was the rst physician to describe gallstone with his observation recorded by
Marcellus Donato in his book De Medica Historia Mirabili Libri Sex:
In the gall bladder many stones were seen, Gentile himself testies, in a certain woman,
whose viscera were removed, so that the body could be embalmed they found in the duct of
the gall bladder at its mouth, a stone tending to green, from which the moderns with right
remark that there was jaundice present [7, p.269].
Included are excerpts from Jean François Fernel (Ioannis Fernelii) (c. 1497–1558),
who provides a clear and accurate depiction of gallstone which remains pertinent
even to this day:
Obstruction, calculus, fullness and emptiness attack the gall bladder. The obstruction is
either of the duct by which the bile is led away from the liver, or of that by which it is dis-
charged from the gall bladder into the intestine. In both, the bowels are obstinate and slug-
gish, feces whitish, the urine is reddish and thick so that it frequently becomes dark, the bile
diffused with the blood throughout the whole body disgures the skin with jaundice. In the
former moreover, the gall bladder is entirely empty: in the latter it is distended by the larger
amount of bile, and is oppressed by various symptoms of great importance [8].
By the later part of the nineteenth century, a variety of signs involving the liver and
biliary system were identied through observation, palpation, percussion, and aus-
cultation as a method for diagnosing diseases. The eponymously named signs are
presented in chronological order based on the earliest date reported and depicted as
initially described by the authors.
7.2 Liver andBiliary Eponymous Signs
7.2.1 Hanot Sign
Victor Charles Hanot (1844–1896) was born in Faubourg Saint-Antoine, Paris,
France. He was appointed extern in medicine in 1869 and intern in 1871, studying
under the aegis of Jean-Martin Charcot (1825–1893) [9–11]. He received his medi-
cal degree based on the thesis titled “Étude sur une forme de cirrhose hypertro-
phique du foie: cirrhose hypertrophique avec ictère chronique” (Study on a Form of
Hypertrophic Cirrhosis of the Liver: Hypertrophic Cirrhosis with Chronic Jaundice)
in 1875, which was later eponymously referred to as Hanot disease or primary bili-
ary cirrhosis [12].
7 Liver andBiliary Signs
239
Hanot was appointed chief of the medical clinic of Professor Ernest Charles
Lasèque (1816–1893) in 1876, Director for the Central Ofce in 1880, agrégé with
his thesis “Du traitement de la pneumonie aiguë” (Treatment of acute pneumonia)
at the Faculty of Medicine in 1883 and Doctor of Hospitals (Saint-Antoine) in 1884
[9–11]. He became a member of the Anatomical Society of Paris in 1873, a full
member in 1875, and editor-in-chief of the Archives Générales de Médecine
(General Archives of Medicine) [9, 11].
Hanot in collaboration with Anatole Chauffard (1855–1932) described a condi-
tion of diabetes, hypertrophic cirrhosis, and skin pigmentation in 1882, and
Schachmann coined the term “diabète bronze” (bronze diabetes) in 1886. The con-
dition was ultimately eponymously named Troisier-Hanot-Chauffard syndrome or
hemochromatosis [13, 14].
As to insight into his character:
A rst-class clinician, he ran an active department at the hospital. He gave close practical
instructions to students, who greatly appreciated his benevolent direction. (…) A spirit of
great stature disappears, admirably gifted, adorned, and cultivated. (…) Profoundly honest,
fundamentally sound, a sure and faithful friend [9, p.736–737].
Hanot described in four patients:
In most cases, jaundice and hepatic pain were accompanied initially by other symptoms,
including anorexia, constipation, general malaise, fatigue, and fever. The four patients I
observed clearly indicated this “febrile” state during the initial period and ares throughout
the disease. (…) Several times, the pain was accompanied by a high fever of 39.5° to 39.8°
and a pulse of 110 or 120. This fever did not last as long as the pain, but the attack was more
violent and more prolonged when it did occur. At other times the painful episodes were
completely afebrile. This initial crisis lasted from one to several weeks. Then, the disease
enters a quiescent period, characterized mainly by chronic jaundice and enlarged liver.
Jaundice is, therefore, one of the most signicant manifestations of the disease. We have
seen in some cases that this was one of the initial signs. It is hardly noticeable at rst but
then increases imperceptibly; at other times, it is intense as soon as it appears. However,
once produced, jaundice persists throughout the course. However, during the long duration,
it may present variations; sometimes veritable green jaundice, sometimes much less
charged. Nevertheless, even though it may be minimum, it remains noticeable and general-
ized. It is always much more than the subicteric hue encountered in many other conditions
[15, p.53–54].
Hanot referred to this condition as hypertrophic cirrhosis and reported on the histo-
pathologic ndings:
But the most characteristic lesions are those of the bile canaliculi; we nd, in fact, espe-
cially in this form, a proliferation of the epithelial cells of these ducts, which are often
inltrated with bile pigment, and an extreme development of the network of canals, not only
outside the lobules but also probably inside the lobules [15, p.58].
Thus Hanot sign or disease is believed to be the condition now recognized as pri-
mary biliary cirrhosis (Table7.1).
7.2 Liver andBiliary Eponymous Signs
240
7.2.2 Rosenbach Sign
Ottomar Ernst Felix Rosenbach (1851–1907) was born in Krappitz (Krapkowice,
Silesia), studied medicine at the Universities of Breslau and Berlin, and received his
medical degree in 1874 [16–18]. He served as an assistant to Wilhelm Olivier Leube
(1842–1922) and Hermann Nothnagel (1841–1905) in the Polyclinic of the
University of Jena from 1874 to 1877 [16].
He was appointed assistant to Julius Friedrich Cohnheim (1839–1884) at the
Allerheiligen-Hospital in Breslau and an associate professor at the University of
Breslau in 1878. Rosenbach was chief in the Department of Medicine at
Allerheiligen-Hospital from 1887 to 1893 and an extraordinary professor in 1888
[16, 17, 19, 20]. He resigned from this hospital in 1893 and the University of Breslau
in 1896, returning to the University of Berlin in 1896 [16, 17, 20].
Rosenbach described the sign of liver pulsation found in tricuspid insufciency
as well as the trembling of the eyelid when the eyes are closed in Grave disease. He
is considered the founder of functional diseases of the stomach. His work spanned
multiple experimental, clinic, pathological, diagnostic, and therapeutic areas.
As to his character:
Rosenbach was an exceptional personality in every respect. Endowed with a penetrating
intellect, he was at the same time of rare kindness of heart and tenderness of feeling. He
practiced innumerable benevolent deeds, always in such a way that no third person knew
about them, and he understood all human weaknesses. His very strongly developed sense of
justice made him always stand up for all the oppressed. Only in the eld of science was
there no compromise for him. Here he fought for what he believed to be right, without
regard for others, and his own advantage. He was cheerful, full of life, and gifted with wit
and humor. (…) He had a sense of all that was good and beautiful in life, art, and science.
All those who were fortunate enough to be among his friends and acquaintances looked up
to him with the greatest reverence and will never forget his memory [20, p.490].
As described by Rose:
In every respect Rosenbach was an unusual personality, a physician the like of whom has
only rarely existed. His diagnoses were remarkably clear-sighted: in the prognoses he but
rarely erred, and in the domain of therapy he was remarkably successful. It is a characteris-
tic fact that a large number of colleagues consulted him for his advice. His love and capacity
for work were truly astonishing. An original thinker of rare perception, he was no slavish
follower of authorities, but claimed the right of working out his problems for himself, and
there were few of these, indeed, to which his reasoning failed to impart a new aspect.
Endowed as he was with great power of perception, gifted with rare kindness of heart and
gentleness of disposition, he did many acts of benevolence, always taking care that they did
not come to the knowledge of that persons. He had a full understanding for human foibles.
His sense of justice was so strongly developed that he invariably came to the aid of those ill
[21, p.858].
7 Liver andBiliary Signs
241
Rosenbach acknowledged that tricuspid insufciency was the most common cause
of liver pulsation:
The earlier view that pulsation of the liver is most commonly directly due to the elevation
and lowering of its surface in tricuspid insufciency, similar to an arterial vessel of the
pulsating inferior vena cava, is true in most cases. The observation to be reported now is
intended to show that there are indeed cases in which a pulsation of the liver, which differs
in no way from that caused by insufciency of the tricuspid nerves, can occur during life
and that, at autopsy, a valvular defect is absent [22, p.498].
He reported the case of an 18-year-old typesetter apprentice with aortic insuf-
ciency (Tab le7.1):
In no heart disease other than insufciency of the aortic valves is there a wide difference in
the initial and nal pressure in the arterial system that even the smallest arteries, including
the capillaries, pulsate and that the whole body shows a strong systolic shock than we must
consider that in such cases distinct liver pulsations are possible [22, p.519].
Thus, Rosenbach sign refers to liver pulsation in patients with aortic insufciency.
7.2.3 Courvoisier Sign
Ludwig Georg Courvoisier (1843–1918) was born in Basel, Switzerland, and
received his surgical training under the aegis of August Socin (1837–1899) and
Johann Jacob Bischoff (1841–1892) in Basel and obtained his medical degree from
the University of Basel in 1868 [23–25]. After graduation, he studied abroad in
London and Vienna and was a military surgeon during the Franco–Prussian War at
the Military Hospital in Karlsruhe, Germany, from 1870 to 1871 [23, 24, 26].
Courvoisier accepted an appointment at the Deaconess Institute, Riehen,
Switzerland, where he later served as a medical director [26]. He habilitated in 1880
and moved to Basel in 1883 as a private practitioner while maintaining an appoint-
ment at the Riehen Hospital. He was an associate professor in 1888 and a full pro-
fessor in 1900. Courvoisier was also president of the Federal Medical Examination
Committee [23–25].
As to his character:
As a physician, Courvoisier was extraordinarily conscientious and faithful to duty, and for
many families, he was the regular resident of old and new, always friendly, sympathetic, and
benevolent. As a diagnostician, he was matter-of-fact and cautious, never hasty and preju-
diced, often hesitant, aware of human frailty; reassuring as a surgeon and never harsh with
a sick person; his technique was not calculated for external effect, but purposeful and delib-
erate: “nil nocere” was his highest principle [24, p.11].
7.2 Liver andBiliary Eponymous Signs
242
In his discussion on the consequence of obstructive gallstones, Courvoisier found
that (Table7.1):
[e]ctasia of the gallbladder is rare if a stone obstructs the common bile duct. (…) In other
kinds of obstruction, ectasia is common, with atrophy occurring in less than half of these
cases. The results of this study have been surprising. It is usually stated in the handbooks
and textbooks that stone obstructing the common bile duct leads to gallbladder dilatation
caused by bile stasis. I found the opposite and must point out that there is no ectasia when
a gallstone blocks the duct. Dilation is indicative of other types of obstruction. If this is
further conrmed, it would be an essential clue in the differential diagnosis [27, p.58].
Courvoisier proposed a pathogenesis for the ndings:
According to an earlier account, choledochal stones usually come from the gallbladder.
However, on their way, the stones, as they pass, as has just been shown, irritate the cystic
duct and partly the gallbladder causing chronic inammation of the gallbladder wall, which
often ultimately results in shrinkage of the duct and gallbladder. If the gallbladder is altered,
even the most severe biliary stasis prevents it from expanding. In other causes of obstruc-
tions, especially those due to tumors, bile ow shows a normal compliant gallbladder
[27, p.58].
Thus, Courvoisier sign refers to a brotic gallbladder secondary to chronic inam-
mation in cases of choledocholithiasis and a distended gallbladder in causes other
than that of gallstone (e.g., tumor).
7.2.4 Rovighi Sign
Alberto Rovighi (1856–1919) was born in Modena, Italy, and received his medical
degree in medicine and surgery from the University of Bologna in 1879 [28, 29]. He
continued his studies in Paris under Jean-Martin Charcot (1825–1893) and Luigi
Luciani (1842–1919) in Florence and was an assistant of pathological anatomy in
Modena under the aegis of Carlo Foà (1880–1971), the laboratory of Friedrich
Daniel von Recklinghausen (1833–1910) and clinic of Adolf Kussmaul (1822–1902)
in Strasbourg in 1883 [29].
Rovighi was an assistant in the medical clinic in Bologna under the direction of
Augusto Murri (1841–1932) in 1884, was appointed lecturer and chair of propae-
deutic medical pathology in 1887, ordinary professor of pathology and preparatory
medical clinic beginning in 1888in Modena and subsequently Sienna, Italy in 1892
[28–31]. He accepted a position at the University of Bologna as an extraordinary
professor of special demonstrative medical pathology in 1894 and was selected as a
full professor in 1901 [28, 29, 31].
As to his character:
Rovighi distinguished himself among his contemporaries because he possessed a broad
physiologic and anatomopathological background in his scientic investigation and sincere
love for science and education. (…) Honesty and goodness were the great virtues that
adorned his life and made his memory dear to his students and colleagues [29].
7 Liver andBiliary Signs
243
Rovighi described the case of a 50-year-old man (Table7.1):
What was most interesting about our subject was the constancy by which the voluminous
mass developed in the left hypochondrium and on the intumescence of the liver and abdo-
men. In addition to the hydatigenic thrill, I found a deep, low sound similar to that of a
vibrating metal string. This particular resonance was felt not only on the most prominent
part of the large cyst of the spleen but also at other points on the mass where the thrill was
less evident. It was heard at a certain distance from the cyst while striking the mass.
Investigating this sound, I dened the exact area on the spleen where the large hydatid was
present. I discovered another one about the size of an apple in the abdominal cavity at the
umbilicus. Then listening to the liver, I heard a distinct resonant sound when the digital or
pleximetric percussion fell on the site of the hydatigenic cyst within the parenchyma of the
liver and a dry and metallic sound when struck at other points in the bowel. I also ascer-
tained that when moderate pressure was exerted with the stethoscope on the cystic tumor,
resonance on percussion acquired a higher pitch. If a solid body is interposed between the
stethoscope and the tumor, the sonority is still perceived distinctly, while the hydatigenic
thrill is no longer felt with the hand [32, p.518]. (…) To me and others who examined my
patient with multiple hydatids in the spleen and abdomen, we were sometimes unable to
perceive the thrill even though it was quite evident at other times. I was often able to elicit
the thrill when provoked in various ways. I found that the best way to make it noticeable is
to place the palm of the left hand rmly on the mass and strike the rst phalange using the
right middle nger. Thus, a vibratory tremor is felt, which should not be confused with
uctuation or other tactile sensations. As we have already seen, this thrill is neither found
in ovarian cysts nor supercial abscesses of the liver [32, p.519–520].
In summary, Rovighi identied that the best method of detecting echinococcal cysts
was a vibratory tremor (thrill) detected through percussion.
7.2.5 Boas Sign
Ismar Isidor Boas (1858–1938) was born in Exin, near Bromberg, province of
Posen-West Prussia. He studied medicine in Berlin under the aegis of Carl Anton
Ewald (1845–1915) and at the University of Halle under Theodor Weber
(1836–1906). He received his medical degree from the University of Halle in 1881
and completed his state licensure examination at the University of Leipzig in 1882
[33–36].
In Berlin, Boas was an assistant to Ewald at Augusta Hospital from 1882 to 1886,
where he studied the physiology and pathology of gastric secretions and gastric
function and described the guaiac test as a method for detecting occult blood in the
stool, among others [33–36]. He was instrumental in being the rst to establish an
independent practice of gastroenterology as a medical specialty and founded a poly-
clinic in gastric and intestinal diseases in 1886 [33–36]. He was appointed professor
of medicine in Berlin in 1907 and Geheimer Sanitätsrat (Privy Medical Councilor)
in 1914 [33]. During National Socialism and anti-Jewish sentiment, he and his fam-
ily ed to Vienna in 1936 [34].
7.2 Liver andBiliary Eponymous Signs
244
He founded and served as the editor of Archiv für Verdauungs- Krankheiten mit
Einschluss der Stoffwechselpathologie und der Diätik (Archives of Digestive
Diseases including Metabolic Pathology and Dietics), the rst specialty gastroenter-
ology journal from 1895 to 1933 colloquially referred to as “Boas Archiv” and
published Allgemeine Diagnostik und Therapie der Magenkrankheiten (General
Diagnosis and Treatment of Gastric Diseases) in 1890, Spezielle Diagnostik und
Therapie der Magenkrankheiten (Special Diagnosis and Therapy of Gastric
Diseases) in 1893, Die Lehre von den Okkulten Blutungen (The Doctrine of Occult
Bleeding) in 1894, and Gesammelte Abhandlungen aus dem Gebiete der
Verdauungskrankheiten (Collected Treatises on Digestive Diseases) in 1906 [33,
34, 36].
He was a corresponding and honorary member of the American
Gastroenterological Association [33]. He and Julius Curt Pariser (1863–1931) were
instrumental in establishing the rst Conference for Digestive and Metabolic
Disease in Bad Homburg in 1914 [33]. The Fachgesellschaft für Verdauungs- und
Stoffwechselkrankheiten (Scientic Society for Digestive and Metabolic Disease)
was founded in 1925 with Boas appointed the rst honorary member in 1927 [33].
He was honored by the Deutsche Gesellschaft für Verdauungs- und
Stoffwechselkrankheiten (German Society for Digestive and Metabolic Diseases)
with a memorial plaque in the Berlin Charité in 1992, and the Boas Medal and Boas
Prize are awarded annually by the German Gastroenterological Association in rec-
ognition for outstanding achievements in gastroenterology [33, 34].
As to a description of his character:
He was a devoted, though strict, father, giving his children the best available education. He
was kind, generous, charitable, and above all, had a keen sense of integrity in both his pri-
vate and professional dealings. Wherever he went, he was the life and soul of the party
[36, p.52].
Boas described a palpatory method for identifying and measuring pain using an
algesimeter to distinguish a gastric ulcer, gastric neurosis, and cholelithiasis:
The pressure points on the spinal column are of diagnostic importance, to which I rst drew
attention. These are either multiple pressure points, randomly distributed on both sides of
the spine, or extensive painful areas, which likewise show no correspondence. This behav-
ior is most pronounced in all gastric and intestinal neuroses but is found generally in male
and female neurasthenics, even without any involvement of the digestive system. Completely
isolated, generally one-sided pressure areas are clearly distinguished from these pressure
points, or better, pressure areas. We can distinguish: i) the pressure points in gastric ulcers
and ii) those in cholelithiasis. The former occurs in typical cases of gastric ulcer, is found
in about a third of all cases, and is located to the left of the spine, on the 12th thoracic ver-
tebral body. There are occasional deviations from this, which is not surprising given the
variable location of the stomach and ulcer. For example, the pain may be higher on the 10th
or 11th thoracic vertebra or lower at the level of the rst lumbar vertebra. Occasionally
there is a corresponding soreness on the right side, but in this case, the pressure point on the
left is the more sensitive. The pressure area in cholelithiasis is also in the region of the 12th
thoracic vertebra, 2-3 nger widths from the vertebral bodies. From there, it often extends
further to the right, sometimes to the posterior axillary line on the left side [37, p.73–74].
(…) The examination of the pressure points is not only of diagnostic but also of therapeutic
7 Liver andBiliary Signs
245
importance, insofar as one can use this to provide objective evidence for progressive
improvement or healing of the disease [37, p.75].
Thus, Boas identied pressure areas on the spine in gastric ulcers and cholelithiasis
(Table7.1). Boas point and Boas sign have been used to describe increased cutane-
ous sensitivity to light touch. Boas point refers to discomfort to the left of the 12
thoracic vertebrae. In contrast, Boas sign refers to discomfort at the right infra-
scapular area and right upper quadrant, which departs from Boas’s description [38].
Gunn and Keddie reported increased sensitivity or hyperesthesia occurring in the
abovementioned areas occurring in 7% of patients undergoing cholecystectomy [39].
7.2.6 Naunyn Sign
Bernhard Naunyn (1839–1925) was born in Berlin, Germany, and studied medicine
under Nathanael Lieberkühn (1821–1887), Karl Bogislaus Reichert (1811–1883),
and Friedrich Theodor von Frerichs (1819–1885) and received his medical degree
from the University of Berlin in 1863 [40, 41].
After qualifying, he served as an assistant in the Frerichs Medical Clinic at
Charité, Berlin. This experience inuenced and imparted to him a profound appre-
ciation of experimental laboratory medicine in understanding disease and its treat-
ment. He habilitated at this same institution in 1867 [42–44]. He was appointed
extraordinary professor and director of clinical medicine at the University of Dorpat
(Tartu) from 1869 to 1871, followed by the same title at the University of Bern,
Switzerland, from 1871 to 1872, and Königsberg from 1873 to 1888 [40–43, 45].
He was chair of medicine at the University of Strasbourg from 1888 to 1904 [40,
41, 45].
Naunyn co-founded with Johannes von Mikulicz-Radecki (1850–1905)
Mitteilungen aus den Grenzgebieten der Medizin und Chirurgie (Communications
from the Border Areas of Medicine and Surgery) in 1869 and with Edwin Klebs
(1834–1913) and Oswald Schmiedeberg (1838–1921) Archives fur Experimentelle
Pathologie und Pharmakologie (Archives for Experimental Pathology and
Pharmacology) in Leipzig in 1871 [40–46]. Naunyn’s primary interest was in clini-
cal and experimental pathology and pathological chemistry, with an emphasis on
diabetes mellitus research [42, 44]. A bronze medal commemorating Bernhard
Naunyn was engraved by Josef Johann Tautenhayn (1868–1962) in 1909 [46].
Naunyn was nominated for the Nobel Prize in Physiology and Medicine for his
research on gallstones in 1925 [47].
As to a description of his character and impetus:
He has been described as “a clinician body and soul.” He knew that the ultimate application
of medical science must be practical, at the bedside, and that science that could not be thus
applied was not worthy of the name. As far as speculation solved problems or set them apart
he was not averse from it, but had no use for it in itself. He was one of the most practical
research worker that there has ever been [48, p.1132].
7.2 Liver andBiliary Eponymous Signs
246
His farewell speech at the medical clinic in Strasbourg in 1904 provides further
insights into the type of person Naunyn was:
When I look back today, gentlemen, my closest students, and assistants always stood at the
top of my clinical work. The gentlemen who gathered around and worked with me were
introduced to science. The memory of this part of my work and activity is, without reserva-
tion, a happy and clear one, and I thank heaven for that. My collaboration with my students
and assistants was the most important part of my life’s work. It is also a source of joy for
me to reect on this part of my work with complete satisfaction. We stood together, gentle-
men, like a circle of friends, where the thoughts and discoveries of each individual became
the property of all through joyful sharing. Stimulating and encouraging each other, we have
never worried about the demarcation of our intellectual property, neither has it been
neglected, and we have all remained friends to this day. As I age, it is no small pride that I
may boast of having such a circle of faithful and dependable friends [49].
Naunyn described a palpatory maneuver for examining the liver in causes of acute
cholecystitis caused by gallstone (Table7.1) (Fig.7.1):
If the liver is swollen as the result of the attack (i.e., recently) the organ is always tender,
and often very acutely so; frequently, it is tender without being swollen. In such cases it is
found that pain is induced when, during a deep inspiration, pressure is made with the hand
projecting as far upwards as possible beneath the right costal border. At the moment when
the liver impinges upon the tips of the ngers the patient experiences a deep–seated pain
which sometimes radiates over the entire hepatic region and on to the epigastrium. Rarely,
liver tenderness is only manifested by tension of the muscles of the anterior abdominal wall
on the right side. In such cases the difference in tension of the right and left side respectively
is best observed in the rectus abdominis [50, p.79].
Fig. 7.1 Naunyn sign (by Ryan Yale)
7 Liver andBiliary Signs
247
Thus, Naunyn sign refers to a tender liver found on inspiratory palpation at the right
costal margin.
7.2.7 Lennhoff Sign
Rudolf Lennhoff (1866–1933) was born in Lüdenscheid, Westfalen, Germany [51].
He served on the medical council of the Society for the Study of Social Medicine
and Hygiene and as a medical statistician in Berlin [51, 52]. The purpose of this
society involved the collaboration of medical practitioners and statisticians inter-
ested in political and social issues [52]. He was also a member and chairman of the
Berlin-Brandenburg Medical Association and editor of the Medizinische Reform
(Medical Reform) [52, 53].
Lennhoff described a nding found on examination of the abdomen as a method
to conrm the diagnosis of an echinococcal cyst (Tab le7.1):
On inspection of the abdomen, one sees a moderate bulging of the hepatic region, project-
ing somewhat beyond the midline to the right. During deep inspiration, two smaller
protrusions are seen on the right, by which palpation shows that they belong to the liver. The
lower left edge of the liver is sharp and rough, the right edge only slightly rmer and
thicker. The entire surface of the organ, including the protrusions, is smooth, and the latter
feels somewhat rmer. Immediately during the initial examination, when I looked at the
patient lying horizontally, I noticed the previously described furrow that formed between
the rib wall and the protrusion as soon as the liver descended during deep inspiration. I then
diagnosed liver echinococcus [54, p.409].
Thus, Lennhoff sign refers to a furrow or crease found on deep inspiration below the
lowest rib and echinococcal cyst.
7.2.8 Mayo-Robson Sign
Biographical information about Sir Arthur William Mayo-Robson (1853–1933) is
found in Chap. 9—Pancreatitis. Mayo-Robson described a nding in patients with
cholecystitis (Tab le7.1):
When seen there was tenderness at a point midway between the ninth costal cartilage and
the umbilicus, which we have found to be almost as signicant of inammatory trouble
about the gall-bladder as is tenderness at McBurney’s point of appendicitis. This sign,
together with slight icterus after each attack, led to the diagnosis of gall-stones, although the
pain had latterly been more especially on the left side of the abdomen. The left-sided pain,
as was pointed out some years ago (by the author), is always associated with adhesions
between the pylorus and gall-bladder with adhesions between the pylorus and gall-bladder
or bile-ducts, and from this and similar cases it almost seems as if, when this event occurs,
a transference of the pain takes place from the right to the left side, as in reected pain in
other parts of the body [55, p.153–154].
Thus, Mayo-Robson sign refers to tenderness located midway between the right
ninth costal cartilage and umbilicus in patients with acute cholecystitis. He also
described another sign in patients with acute pancreatitis, spontaneous pain at the
left costovertebral angle (see Chap. 9).
7.2 Liver andBiliary Eponymous Signs