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9.2.8 Mallet-Guy Sign
Pierre Albert Mallet-Guy (1897–1995) was born in Beaune, France, and received
his medical degree from the University of Lyon in 1925. At the University of Lyon,
he served as head of the surgical clinic in 1927, associate professor in 1939, and
professor of surgical pathology in 1946 [40]. He was appointed professor of the
surgical clinic A and director of the surgical research unit of the National Institute
of Health and Medical Research at the Edouard Herriot Hospital in Lyon in 1958
[40]. He served as mission ofcer by the General Directorate of Cultural Affairs to
numerous countries, including the USA, in 1948 and later annotated an honorary
foreign member for his distinguished service [40].
Among his many accolades, Mallet-Guy was recognized for his valor by being
decorated with the War Cross, ofcer of the Legion of Honor, and commander of the
Order of the Yugoslav Star, Doctor honoris causa at the University of Giessen and
member of the French Association of Surgery Board of Directors [40]. He was also
a member of the Academies of Medicine and Surgery, the American College of
Surgeons, and the Belgian Society of Surgery, to name a few. He was editor-in-chief
of Lyon Chirurgical [40].
Mallet-Guy described, in 1943, a maneuver used to detect a painful point in
chronic pancreatitis (Fig.9.1):
The fasting patient is placed in the right lateral decubitus position, with the legs semi-exed
on the abdomen. The tips of the ngers are placed 3 to 4cm along the costal margin at the
9th cartilage and are easily inserted under the costal arch by depressing the anterior abdomi-
nal wall in the lateral direction toward the vertebra. This position allows the pancreas to be
more easily explored. The examiner identies a palpatory point causing sharp pain that
conrms the diagnosis [41, p.175].
He further claried precisely the location and direction of the ngers:
Place the extended ngers beneath the costal margin and directed them superiorly. When
the ngertips are deep under the diaphragm, raise the heel of the hand and palpate the pan-
creas under the ngers. This maneuver displaces the stomach inferiorly and medially [41,
p.175].
Mallet-Guy reported his experience with this sign:
This is a sign of pancreatitis. My personal experience with 34 patients suffering from
chronic pancreatitis (in 23 the disease was conned to the left side of the pancreas) allows
me to use this sign in cases where the diagnosis was unclear [41, p.174–175].
He called for the need to evaluate this nding further in order to conrm its ability
to distinguish chronic pancreatitis from other conditions in this abdominal region:
I would like to see a systematic investigation of this symptom. It is always present when the
disease is located on the left side of the pancreas. It is often possible to distinguish this
condition from renal disease, post-operative peptic ulcer disease, and splenic vein thrombo-
sis [41, p.175].
Thus, Mallet-Guy sign is the technique for identifying the painful point in chronic
pancreatitis (Table9.1).
9 Pancreas Signs
301
Fig. 9.1 Mallet-Guy sign (by Ryan Yale)
9.2.9 Imrie Sign
Clem William Imrie (1943–) graduated from the University of Glasgow Medical
School with a Bachelor of Medicine and Bachelor of Surgery degree in 1967 [42].
He completed his surgical residency in the West of Scotland, at St. George’s Hospital
with Sir Rodney Smith (1914–1998), and fellowship training in Europe and the
USA [43]. Imrie was a surgeon at the Glasgow Royal Inrmary from 1969 to 2007,
rising to consultant surgeon in 1977 and professor of surgery Lister Department of
Surgery at the University of Glasgow, UK, from 1996 to 2007 [44]. He was elected
a fellow of the Royal College of Physicians and Surgeons in 2002. He is currently
professor emeritus, Department of Surgery at the Glasgow Royal Inrmary, National
Health Service Greater Glasgow and Clyde [42].
He served as president of the International Society of Pancreatology from 1994
to 1996, the European Pancreatic Club from 1989 to 1990, the Pancreatic Society of
Great Britain and Ireland from 1990 to 1991, and the International Pancreatic
Association from 1994 to 1996 [42, 43]. He is the recipient of the George E.Palade
9.2 Eponymic Signs
302
Prize from the International Association of Pancreatology [44]. His name is epony-
mously ascribed to a score devised to determine the severity and predict mortality
in acute pancreatitis (Glasgow–Imrie Criteria for Severity of Acute Pancreatitis) [44].
Imrie described a nding occurring in patients with acute pancreatitis (Table9.1):
Facial ushing in the absence of pyrexia is a frequently observed clinical sign in the initial
48 hours after the onset of acute pancreatitis. (…) The ushing was readily observed in the
initial 12 hours after admission in most patients, but a minority developed the striking
appearance between 12 and 36 hours after admission. It is unusual for the ushing to be
present for approximately a day [45, p.593].
He postulated that the cause of the ushing was due to the release of vasoactive
peptides into the blood, secondary to the inammation of the pancreas.
9.2.10 Baid Sign
Jai Chand Baid (1947–) received his surgical training in Rajasthani, India, in 1970.
He was an associate professor at Jawaharlal Nehru (JLN) Hospital in Rajasthani in
1991 [46]. He also was a general surgeon at the Gheesibai Memorial Mittal Hospital
and Research Centre, St. Francis Hospital, Ajmer, Rajasthan, and professor and
head of the Department of Surgery at JLN Medical College Ajmer, Rajasthan [47].
Baid served as president of the Association of Surgeons of India (ASI) Rajasthan
Chapter and member of the Governing Council of ASI. He was the former vice-
president of the Association of Colon and Rectal Surgeons of India (ACSRI) and a
member of the International Society of Coloproctology. He is an honorary fellow of
the ACSRI [47].
Baid described a bedside method for detecting a pancreatic pseudocyst. He noted
that in patients with a Ryle tube (nasogastric tube) (Table9.1):
I have noted a physical sign that can help immediately in the clinical diagnosis. A Ryle tube
is palpated over the lump in the epigastrium in thin patients suffering from pancreatic cyst
because it provides the counter force to the palpating hand, and as the cyst enlarges and
becomes tense it pushes the stomach forward. This results in the obliteration of the gastric
lumen and the space between the stomach and the parietes [48, p.1167].
Baid noted that the tube is more likely to be palpated if the cyst is located behind the
stomach and in patients with a thin abdominal wall. In patients with a thick abdomi-
nal wall, the test is more likely to be negative because the abdominal wall fat
impedes the ability to palpate the tube. No studies have evaluated the sensitivity or
specicity of this sign.
9 Pancreas Signs
303
Table 9.1 Pancreas signs
Name Year Description of sign Signicance
Fitz [4] 1889 Sudden, generally severe, and intense gastric or
epigastric abdominal pain, vomiting, and
sometimes great prostration. Initially, the upper
abdomen, especially the epigastrium, is
distended, tympanitic, and sensitive. Later, the
entire abdomen is moderately swollen, tense,
and tympanitic
Acute pancreatitis
Körte (Koerte) [16] 1898 A palpable mass is felt in the epigastrium at the
site of the pancreas when the abdominal wall is
slack and thin; the stomach and intestines are
empty; abdominal distention has improved or
is eliminated by gastric lavage; or when the
tension in the abdominal muscles has improved
or the pain reduced through anesthesia.
Pancreatic swelling is also felt when the acute
stage of the disease has resolved, and the pain
and distention of the epigastrium have subsided
Acute pancreatitis
Halsted [23] 1901 The white print of the ngertips is seen in a
slightly cyanosed eld just over the site of
greatest pain, located slightly above and to the
right of the umbilicus
Acute hemorrhagic
pancreatitis
Mayo- Robson [28] 1907 Acute inammation is characterized by a
tender spot above and to the right of the
umbilicus
Acute pancreatitis
Löwi (Loewi) [35] 1907 In patients with diabetes mellitus installing
adrenaline drops in the eyes causes marked
pupillary mydriasis
Pancreatic
insufciency
Goblet [36] 1913 Isolated distension of the transverse colon Necrotizing
pancreatitis
Frostberg [38] 1938 Deformity of the descending part of the
duodenum, which radiographically assumes the
shape of an inverted gure “3”
Inammatory and
benign or
malignant process
involving the head
of the pancreas
Mallet- Guy [41] 1943 The fasting patient is placed in the right lateral
decubitus position, with the legs semi-exed on
the abdomen. The tips of the ngers are placed
3–4cm along the costal margin at the ninth
cartilage. The ngers are inserted under the
costal arch by depressing the anterior abdominal
wall in the lateral direction toward the vertebra.
The examiner identies a palpatory point
causing sharp pain, conrming the disease
Chronic
pancreatitis
Imrie [45] 1974 Facial ushing without fever Acute pancreatitis
Baid [48] 1976 A Ryle tube is palpable over the lump in the
epigastrium in patients with a thin abdominal
wall if the cyst is located behind the stomach
Pancreatic
pseudocyst
9.2 Eponymic Signs
304
9.3 Conclusion
Körte, Mayo-Robson, and Mallet-Guy reported three palpatory signs of acute pan-
creatitis. Körte described a palpatory mass, while Mayo-Robson and Mallet-Guy a
tender abdominal point. Advanced computer tomographic imaging and laboratory
tests have altered how physicians diagnose this disease. These historical signs shed
light and provide a better perspective of how physician diagnosed disease at a time
without sophisticated diagnostic tools.
References
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2. Dunglison R.The practice of medicine, or a treatise on special pathology and therapeutics, vol.
2. Philadelphia, PA: Lea & Blanchard; 1842.
3. Birch-Hirschfeld FV.Lehrbuch der pathologischen Anatomie. Leipzig: FCW Vogel; 1895.
4. Fitz RH.Acute pancreatitis: a consideration of pancreatic hemorrhage, hemorrhagic, suppura-
tive, and gangrenous pancreatitis and of disseminated fat-necrosis. Boston, MA: Cupples and
Hurd; 1889.
5. [No author]. Reginald Heber Fitz. Bost Med Surg J. 1913;169:625–6.
6. Kelly HA.American medical biographies: Fitz, Reginald Heber (1843–1913). Bost Med Surg
J. 1919;180:75–7.
7. Morrison H.Reginald Heber Fitz’s contribution to the development of medical education and
practice in America. Bull Hist Med. 1951;25:60–5.
8. Morrison H.Reginald Heber Fitz. Bull Hist Med. 1941;10:250–9.
9. [No author]. Deaths. JAMA. 1913;61:1471–2.
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MA: Boston Medical and Surgical Journal Publications; 1908. p. 7–12.
12. Winkelmann O.Körte, Werner. In: Neue Deutsche Biographie, Bd. 12. Munich: Duncker &
Humblot; 1980. p. 395–6.
13. Körte W (1853–1937). Plarr’s lives of the fellows. London: Royal College of Surgeons of
England; 2013. https://livesonline.rcseng.ac.uk/client/en_GB/lives/search/detailnonmodal/
ent:$002f$002fSD_ASSET$002f0$002fSD_ASSET:376508/one?qu=%22rcs%3A+E00432
5%22&rt=false%7C%7C%7CIDENTIFIER%7C%7C%7CResource+Identier. Accessed 24
Oct 2022.
14. Körte W.Ein großer Chirurg seiner Zeit. Neuruppin: Berliner Chirurgische Gesellschaft; 2003.
https://bchirg.de/2003/08/werner-korte-ein-groser-chirurg-seiner-zeit/. Accessed 16 Oct 2022.
15. Brentano A.Zum Gedächtnis Werner Körtes. Dtsch med Wochenschr. 1937;63:1923.
16. Körte W.Die eitrige Pankreasentzündung, Pankreasabscesse und peripankreatische Eiterung.
In: Die chirurgischen Krankheiten und die Verletzungen des Pankreas. Stuttgart: Verlag von
Ferdinand Enke; 1898. p. 147–55.
17. [No author]. Obituary: W.S.Halsted MD.Har; FRCS.Eng. and Edin. Br Med J. 1922;2:663.
18. Rankin JS.William Stewart Halsted: a lecture by Dr. Peter D.Olch. Ann Surg. 2006;243:418–25.
19. MacCallum WG.Biographical memoir of William Stewart Halsted, 1852–1922. In: National
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1933. p. 151–70.
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of England; 2012. https://livesonline.rcseng.ac.uk/client/en_GB/lives/search/detailnonmodal/
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22. [No author]. Obituary: William Stewart Halsted. Cal State J Med. 1922;20:420.
23. Halsted WS.Retrojection of bile into the pancreas: a cause of acute hemorrhagic pancreatitis.
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25. [No author]. Sir Arthur Mayo-Robson, KBE, CB, CVO, FRCS. Ann R Coll Surg Engl.
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27. [No author]. Obituary: Arthur William Mayo-Robson, KBE, CB, FRCS. Lancet.
1933;222:948–9.
28. Mayo-Robson AW, Cammidge PJ.The pancreas, its surgery and pathology. Philadelphia, PA:
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29. Kufer SW.Otto Loewi, 1873–1961. J Neurophysiol. 1962;25:451–3.
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45. Imrie CW.Facial ushing in acute pancreatitis. Br Med J. 1974;4:593.
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307© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2023
S. H. Yale et al., Gastrointestinal Eponymic Signs,
https://doi.org/10.1007/978-3-031-33673-7_10
Chapter 10
Intra-Abdominal andDiaphragm Signs
10.1 Introduction
Intra-abdominal signs within the abdomen may involve the peritoneum and primar-
ily, or secondarily, the diaphragm. The word “diaphragm” originated from ancient
Greek and was used by Galen of Pergamon (129–c. 216) in reference to that
structure that partitions the thorax from the abdomen [1]. This chapter includes signs
found extra-abdominally that should raise suspicion for an intra-abdominal process
(e.g., Oehlecker and Kehr signs) and intra-abdominal processes, including intestinal
perforation and hemorrhage, adhesions, ascites, peritonitis, and subphrenic abscess.
The signs are listed chronologically, beginning from the earliest date of the discov-
ery. They serve as the method for diagnosis before the advent of computer tomogra-
phy and ultrasonographic imaging of the abdomen. These signs have not been well
studied; thus, their utility in clinical practice remains unknown. They are historically
signicant as a hands-on approach to diagnosis as they provide the learner with a
better understanding and appreciation of the underlying pathophysiologic process.
10.2 Eponymic Signs
10.2.1 Hippocratic Facies (Sign)
Hippocrates (c. 460–c. 370 ), a Greek physician, was born on the Aegean
Island of Cos. Little historical information is available about his life as it is chal-
lenging to distinguish which writings were attributed to him since physicians at that
time did not sign their works. He is recognized as the “father of medicine,” using the
constructs of philosophy as the basis for medical diagnosis, separating philosophy
from medicine, and cultivating both the art and science of medicine [2, 3].
308
Hippocrates described the physical appearance of the patient with acute peritoni-
tis during the agonal state in the Book of Prognostics (Table 10.1):
[f]or if they shun the light, or weep involuntarily, or squint, or if the one be less than the
other, or if the white of them be red, livid, or has black veins in it; if there be a gum upon
the eyes, if they are restless, protruding, or are become very hollow; and if the countenance
be squalid and dark, or the color of the whole face be changed—all these are to be reckoned
bad and fatal symptoms. (…) [b]ut if the eyelid be contracted, livid, or pale, or also the lip,
or nose, along with some of the other symptoms, one may know for certain that death is
close at hand [4, p.237].
The observations by Hippocrates were used to describe acute and progressive dis-
ease, and a “Hippocratic facies” is still used today to describe the morbid appear-
ance of patients in an advanced disease state such as that caused by untreated
peritonitis.
10.2.2 Stokes Sign
William Stokes (1804–1878) was born in Dublin, Ireland, and received his medical
degree from the University of Edinburgh, Scotland, in 1825 [5]. His rst appoint-
ment was as a physician at the Dublin General Dispensary, followed by Meath
Hospital in 1826. He served as president of the King and Queen’s College of
Physicians of Ireland in 1849 [5, 6].
Stokes was a co-founder of the Pathological Society of Dublin in 1838 and presi-
dent of the British Medical Association and Royal Irish Academy in 1847 [7].
Among his many honors and accolades, he received an honorary medical degree
from the University of Dublin in 1839, a D.C.L. from Oxford, and an L.L.D. from
Cambridge and Edinburgh [6]. He was nominated by the crown as a representative
of Ireland on the General Medical Council, a position he served from 1858 to 1877,
honorary member of the National Institute of Philadelphia, and recipient of the
insignia of the Prussian Order of Merit from the Emperor of Germany [6, 8].
He is best recognized for his works titled A Treatise on the Diagnosis and
Treatment of Diseases of the Chest (1837), The Diseases of the Heart and Aorta
(1854), and Lectures on Fever (1876) [6, 8].
As to a description of his character:
As a hospital physician and clinical teacher, he was pre-eminent, setting an example to
all—colleagues, practitioners, and students alike—of painstaking accuracy and faithful-
ness. He was remarkable for grace of manner, courtesy, earnestness, and felicity of lan-
guage. He was a man of taste and literary attainments; and as one who seems to have known
and admired him testies, “his social qualities were of the most genial and agreeable nature;
his benevolence was unbounded, and his kindliness of heart and disposition endeared him
to all with whom he came in contact.” [9, p.765].
Stokes, in his discussion of enteritis, described the following nding:
10 Intra-Abdominal andDiaphragm Signs
309
In cases of this kind where the diagnosis depends as much on negative as on positive cir-
cumstances, it is of importance to have a direct sign by which we may be able to ascertain,
with some degree of certainty, the existence of a suspected enteric inammation, and I think
I have discovered one, which I believe has not been as yet noticed; this is increased pulsa-
tion of the abdominal vessels [10, p.181]. From these circumstances I was led to conclude,
that, in cases of acute inammation of the digestive tube, there would be increased pulsation
of the abdominal aorta; and on following up the investigation by examining several persons
who had distinct and well-marked intestinal inammation, I found that my conclusions
were well grounded [10, p.182]. I drew your attention at my last lecture to the increased
pulsation of the abdominal aorta and its immediate branches and stated that I look upon this
as a direct sign of abdominal inammation. (…) What I wish to draw your attention to, is
this: where we have this symptom in addition to other signs of inammation of the digestive
tube, it is of considerable value as a diagnostic [10, p.183].
Thus, Stokes sign refers to the marked pulsation of the abdominal aorta and its
immediate larger arterial branches in patients with enteritis (Table10.1).
10.2.3 Duchenne Sign
Guillaume-Benjamin-Amand Duchenne (1806–1875) was born in Boulogne,
France, and qualied in medicine from the University of Paris in 1831 [11, 12]. He
initially returned to Boulogne as a general practitioner in 1831 and subsequently
Paris to pursue further clinical opportunities in 1842 [11–13]. Interestingly,
Duchenne never sought out an academic appointment or committees. Duchenne’s
interests were in electrophysiology and neuromuscular disorders [14, 15]. He
described progressive muscular atrophy (Duchenne–Aran disease), glosso-labio-
laryngeal paralysis and coined the term pseudo-hypertrophic muscular paralysis
and locomotor ataxia [13, 14]. He published De l’électrisation localisée et de son
application à la pathologie et à la thérapeutique (Localized electrication and its
application to pathology and therapy) in 1855 and Physiologie des mouvements,
démontrée à l’aide de l’expérimentation électrique et de l’observation clinique et
applicable à l’étude des paralysies et des déformations (Physiology of movements,
demonstrated using electrical experimentation and clinical observation and applica-
tion to the study of paralysis and deformities) in 1867 [15, 16].
As to his character as described by Collins:
But the fruit of his labors he submitted with condence to the medical profession at home
and abroad, who, not distracted by the sight of the travail or prejudiced by the aggressive-
ness of the creator, sat in clam judgement upon it and bestowed praise whenever it was
merited and gave credit whenever it was due. Indeed, there is much in Duchenne that
reminds of Plato. The self-belief, the equanimity, the desire to abide by the collective judg-
ment of his fellow men, the willingness to argue his contention with every corner, and his
abiding faith in his own observations and deductions, all suggest the immortal Æginian [11,
p.51]. (…) [h]e combined the moral qualities of perseverance, endurance, and self- reliance,
which are the possession of some many obscure heroes of the seas for whom the accom-
plishment of dity is adequate reward. (…) He was independent, ardent, tenacious. These
were his dominant racial qualities, and they were the foundation of his whole career. He was
10.2 Eponymic Signs
310
not easily discouraged and pursued his research and experiments with a patience and perse-
verance unbounded [11, p.54].
Duchenne described a nding observed in the abdomen in cases of diaphragmatic
paralysis:
These are noticeable during respiration and are as follows: At the moment of inspiration the
epigastric and hypochondriac regions are depressed although the chest dilates; during expi-
ration, these movements are reversed. When the diaphragm is merely weak these signs are
seen only during forced respiration, but during tranquil breathing the bulging of the belly
and the expansion of the chest, and vice versa, occur together, as in health. When the dia-
phragm is palsied on one side only, these signs are seen only on the palsied side. Respiration
is quicker than usual, but is without serious difculty during repose [17, p.330].
Thus, Duchenne sign refers to the depression of the epigastrium and hypochondrial
regions during inspiration in the case of diaphragmatic paralysis (Table10.1).
10.2.4 Pfuhl–Jaffé Sign
10.2.4.1 Eduard Pfuhl
Johann Eduard Pfuhl (1852–1917) was born in Berszienen (Kirchspiel Grünheide)
Insterburg district, Russia, and received his medical degree from Kaiser Wilhelm
Academy in 1876 [18]. He was an assistant physician at Mercy Hospital, Königsberg,
from 1878 to 1881; professor at the Kaiser Wilhelm Academy from 1886 to 1891,
the Institute for Infectious Disease in Berlin from 1891 to 1894, and Strasbourg
from 1894 to 1898 [18]. He returned to Kaiser Wilhelm Academy in 1898 where he
later served as professor of the Hygienic Chemical Laboratory until 1908 [18].
Pfuhl reported the case of a right-sided pyopneumothorax and a method for dis-
tinguishing a subphrenic abscess from pyopneumothorax:
The following observation concerns a case of purulent exudate, which occurred due to a per-
forating duodenal ulcer and formed between the convexity of the liver and the lower surface
of the right half of the diaphragm. Like liver abscesses and echinococcus tumors, it had risen
into the right thoracic space, pushing the diaphragm upwards, the heart upward to the left, and
the liver downwards, enlarging the right thoracic space. Eventually, the lungs were perforated,
and air leaked into the pus-lled cavity. These conditions caused complex symptoms to
develop, consistent with a right-sided pyopneumothorax [19, p.57]. (…) In the case of a
thoracentesis, the behavior of the respiratory movements visible on the manometer should
provide a point of reference. Within the pleural space, the pressure falls during inspiration and
rises during expiration; accordingly, we see the mercury in the manometer rise on expiration
and fall on inspiration. Conversely, ndings below the diaphragm behave differently: during
inspiration, where the diaphragm descends, the pressure (and thus the mercury) must rise. In
our case, unfortunately, not enough attention was paid to this moment because we had no
suspicion of an error. Slight respiratory excursion commonly causes only a 2mm deection
on manometry. It is typically greater, although not consistently, between 3 to 6mm in patients
with pleuritic exudates and at least 10mm in severe dyspneic movements [19, p.60].
10 Intra-Abdominal andDiaphragm Signs