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10.2.4.2 Karl Jaffé
There is limited historical information on Karl Jaffé (1854–1917). Born in Hamburg,
Germany, he studied medicine in Hamburg and Strasbourg and practiced gynecol-
ogy in Hamburg. In 1881 he was an assistant physician at the Hamburg General
Hospital [20].
In a lecture delivered to the Hamburg Medical Society on December 14, 1880,
Jaffé described two cases of subphrenic abscess extending to the thorax causing a
pleural empyema and reported on a physical examination method to distinguish
these two entities:
Next to the history, the physical examination comes into consideration, and it is here that
the clinician can prove his reputation as a diagnostician. Suppose we have found an inam-
matory exudate in the lower part of the thorax, and the test puncture has revealed a pus-like
consistency. The question arises: Is the abscess cavity above or below the diaphragm? (…)
Pfuhl drew attention to another physical symptom that can support the diagnosis. During
the respiratory movements of the thorax, the pressure conditions in the thoracic cavity must
be exactly the opposite of those in the abdominal cavity. In the latter, inspiration produces
an increase, and expiration a diminution of pressure. In the thorax, the reverse relationship
occurs. If a manometer attached to the puncture cannula is inserted into the abscess, the
pressure uctuations occurring during respiration movements will allow a direct conclusion
as to whether the cannula is above or below the diaphragm [21, p.215].
Thus, Pfuhl–Jaffé sign refers to the increase in manometric pressure during inspira-
tion and the decrease in subdiaphragmatic manometric pressure during expiration in
a subphrenic abscess (Table10.1).
10.2.5 Federici Sign
Cesare Federici (1838–1892) was born at Serravalle di Chienti (Province of
Macerata), Italy, and studied medicine at the Universities of Camerino, Bologna,
and Florence, Italy [22–24]. He was appointed lecturer on materia medica and clin-
ics at the University of Camerino in 1861, full professor in 1863, and chair of spe-
cial pathology at the propaedeutic medical clinic in 1886 [22–24]. He was a
professor and director of the medical clinic at the University of Palermo in 1870 [22,
23]. Here, he was promoted to professor extraordinary in 1872 and professor ordi-
nary of physic in 1873 [22, 24]. He was elected chair and professor of clinical medi-
cine at the Institute of Higher Studies and Specialization, Florence, in 1883. He was
also appointed as director-in-chief of the government’s baths at Montecatini [22, 24].
Among his many appointments, he served on the boards of the Superior Council
of Public Education; the administrative council of the Hospital of Santa Maria
Nuova, and the Provincial Health Council, Florence; and was a member of the town
council of which he provided services involving issues related to hygiene, educa-
tion, and health to Tuscany, Italy [22–24].
10.2 Eponymic Signs
312
A description of his character as articulated by Grocco:
Precise, clear, and complete in describing and assessing symptoms and distinguishing the
experimental from the clinical sciences. He was stringent in diagnostic inductions and
could conrm a disease based on vast exceptional knowledge and personal experience.
Federici was also likable and impressive, arousing genuine enthusiasm in his pupils. With a
candid soul, erce patriotism, exuberance in family affections, and loyal friendships,
Federici left an everlasting impression of himself wherever he went. The proof of this is the
strong echo of pain that reverberated from Florence and in every part of Italy at the
announcement of his death [24, p.121].
Federici wrote in his paper titled “Istoria di una rara oppilazione dell’intestino”
(History of a rare oppilation of the intestine), regarding the nding he reported in his
paper “La propagazione dei suoni del cuore in ordine alla diagnosi sica dello
stomaco” (The propagation of heart sounds in order to the physical diagnosis of the
stomach):
In my other writing, I distinctly spoke of a precious sign to dene the size of the stomach.
That is the transmission of heart sounds within an area that is precisely the size of the ven-
tricle. I found that air entering the peritoneal cavity formed a wide space bounded and
enclosed by the diaphragm. The air in this space could be heard as perfectly as stomach air.
Here is a sign of the clearest evidence for intestinal perforations [25, p.92–93].
He believed this was caused by air within the peritoneal cavity. However, the patho-
physiologic mechanism involves a uid exudate within the peritoneum. Thus,
Federici sign refers to auscultation of normal cardiac sound in the abdomen in intes-
tinal perforation (Table10.1).
10.2.6 Thomayer (Toma) Sign
Josef Thomayer (1853–1927) was born in Trhanov, Domažlice District (today
Czech Republic), and received his medical degree from the Charles-Ferdinand
University in Prague at Karlova, in 1876 [26–28]. He completed an internship at
Garrison Hospital in Prague and was a demonstrator at the Institute for Pathology
and Anatomy at the General Hospital. Thomayer was an assistant at Jan Nepomuk
Eiselt’s (1805–1868) internal medicine clinic, habilitated and appointed head of the
rst Czech University Polyclinic in 1885, extraordinary professor in 1886, and full
professor in 1897 [26–29]. He was head of the second internal clinic of the Faculty
of Medicine, Charles-Ferdinand University, Prague, from 1902 to 1921 [26–28].
He wrote literary works under the pseudonym “R.E.Jamot.” Thomayer Hospital
is named in his honor in the Prague district of Krč. He co-founded Sborník Vyděčíky
(Collected Papers), rst published in 1885 [27, 29].
As to his character as described by Jedlička:
Thomayer made the polyclinic famous both in terms of medicine and teaching. The poly-
clinic was highly sought after by patients, as Thomayer devoted much of his energy to it and
was there even on Sunday mornings. Medical students also diligently visited the polyclinic.
There, the extraordinary didactic talent of Thomayer shone. He lectured in a sonorous voice
amid deep silence and with listeners’ greatest attention. He was an excellent speaker and
10 Intra-Abdominal andDiaphragm Signs
313
instilled a clear picture of the disease in the brains of his students by drawing attention to
the main characteristic signs of the disease, by which it can be more easily recognized [29,
p.554].
Thomayer identied a method for differentiating inammatory conditions of the
peritoneum (e.g., carcinomatosis, tuberculosis) from non-inammatory conditions
(e.g., simple ovarian cysts):
If we now consider the ve cases of carcinoma and three cases of tuberculosis of the peri-
toneum, which is always lled with more or less copious amounts of uid, we see a peculiar
nding on percussion of the abdominal cavity. Instead of the crescent-shaped mufed area
which we nd in ordinary ascites without inammatory complications on the part of the
peritoneum over the uid-lled space, we see in our cases that the dimensions and localiza-
tion of both the tympanitic and the mufed districts are quite different. In all cases, the
tympanitic intestinal sound was predominantly found over the abdomen’s right half. In
contrast, the dull liquid sound was predominantly found over the abdomen’s left half. (…)
As has already been remarked and partly explained, the anatomist has not always empha-
sized this relationship. However, it is certain that in other cases of tuberculosis and carcino-
mas of the peritoneum, the small intestine loops often stick together due to inammatory
changes in the intestinal serosa and are pushed together like a ball. However, the same
changes in the rest of the peritoneum must mean that the intestinal loops, glued together like
a ball, are shifted to the right half of the abdomen. It is well-known what changes occur in
the mesentery and omentum in both forms of the disease [30, p.404].
As to the proposed pathogenesis of this clinical and autopsy ndings:
Based on these conditions, it is self-evident why, especially in the case of scirrhous forms of
cancer, the lump of the small intestine is shifted more to the right side. In this form of the
disease, however, the mesentery often shrinks to an extraordinary degree; consequently, the
bundle of small intestine must follow the shrinking mesentery, and as this originates on the
right side, the small intestine must then be found more in the right than in the left half, pro-
vided that particular circumstances do not prevent it from such displacement. The outpour-
ing of the liquid exudate into the abdominal cavity and the shrinking of the mesentery
sometimes happens simultaneously since the liquid exudate, the free ascites uid, depends
on the anatomical changes in the peritoneum. Because of this, it happens that as long as the
ascites uid is not extraordinarily copious and does not owe its formation to the compression
of blood vessels, the effusion surrounds the loops of the small intestine and, as they are dis-
placed to the right, accumulates primarily on the left. Based on these conditions, it is clear
that under such circumstances, the result of percussion is different from that in ordinary free
ascites. Although the preceding arguments concern only carcinoma of the peritoneum, the
same applies, mutatis mutandis, to tuberculosis. In tuberculous peritonitis, shrinking pro-
cesses occur both in the omentum and mesentery, resulting in the loops of the small intestine
experiencing a fate similar to that of carcinoma. For this reason, the schemes showing the
percussion ratios are very similar and analogous in both diseases [30, p.405–406].
Thus, Thomayer (Toma) sign refers to the ndings of tympanitic sounds on percus-
sion located over the right side and dullness to percussion on the left side of the
abdomen in patients with tuberculosis peritonitis and peritoneal carcinoma
(Table10.1). Contraction of the mesentery causes the intestines to be drawn to the
right causing a tympanic percussion sound. At the same time, ascitic uid collects
on the left side of the abdomen, causes a dull percussion sound.
10.2 Eponymic Signs
314
10.2.7 Clark Sign
Alonzo Clark (1807–1887) was born in Chester, Massachusetts, USA, and received
his medical degree from the College of Physicians and Surgeons (currently Columbia
University Vagelos College of Physicians and Surgeons), NewYork City, in 1835.
He was an intern at the NewYork Hospital until 1837 and studied abroad in London
and Paris in 1837 [31–34].
Clark was appointed professor of pathology and materia medica at the University of
Vermont Medical School, Burlington [31, 34]. He served as chair of physiology and
pathology at the College of Physicians and Surgeons from 1848 to 1885, as visiting
physician at Bellevue Hospital, NewYork City, in 1847 (later consulting physician),
and as professor and chair of pathology and practical medicine at the College of
Physicians and Surgeons from 1855 to 1885 [31–33]. He was appointed the dean and
president of the College of Physicians and Surgeons from 1875 to 1885. He also served
as consulting physician at St. Luke’s and Roosevelt Hospitals in NewYork City [34].
He was a member of the pathological society and was elected president of the
NewYork Academy of Medicine and State Medical Association in 1853 [31, 34].
The Alonzo Clark Scholarship Fund was established as a memorial endowment at
the College of Physicians and Surgeons [35].
His character as described by Delaeld:
In looking back over Dr. Clark’s life, it seems to me that, perhaps, one of its most useful
results was the inuence it exerted on the medical profession. Here was a man whom every-
one knew, who had attained to the highest honors in the profession, and the largest success in
practice, and yet no one could accuse him of a mean or an unworthy act-no man was his
enemy. He shunned publicity and notoriety in every form; medical politics were unknown to
him; he appeared but rarely in the medical societies or the journals; and yet everything came
to him. He never tried to do anything but to learn all he could about the science and art of
medicine, and to communicate this knowledge to others; and behold, honors, practice, wealth,
were added to him. How many a struggling and discouraged physician had looked at Dr. Clark
and taken heart once more to walk in the narrow and straight way of integrity [33, p.124].
As described by Elliot:
His commanding and graceful presence, his pleasant manners, his mastery of the English
language, his distinct and elegant enunciation, the knowledge of his subject, apparently inex-
haustible, and his scholarly methods, command instant and persistent attention [36, p.501].
In Clark’s discussion of intestinal perforation in typhoid fever, he reported:
Suddenly severe pain sets in, oftenest in the lower part of the abdomen, and spreads rapidly;
the pulse is quickly accelerated and becomes small. And it has been lately stated that in this
and other intestinal perforations the gases of the bowels, escaping into the peritoneal cavity
will give resonance to percussion over the lower part of the liver [37, p.1136].
Thus, Clark sign represents resonance on percussion over the lower hepatic
region in cases of intestinal perforation and intraperitoneal air (Table10.1).
10 Intra-Abdominal andDiaphragm Signs
315
10.2.8 Fürbringer Sign
Paul Walther Fürbringer (Fuerbringer) (1849–1930) was born in Delitzsch, Prussian
Province of Saxony, near Leipzig, and studied medicine in Jena and Berlin, Germany
[38]. He was an assistant in the Pathological Institute under the aegis of W.Müller
in Jena from 1872 to 1874 and assistant to Nikolaus Friedreich (1825–1882) at the
clinics of the University of Heidelberg, Germany [38].
Fürbringer habilitated in pharmacology and medicinal chemistry in 1876 and
was appointed extraordinary professor and chief of the district polyclinic in Jena in
1879 [38]. He was a professor of dermatology at the University of Jena in 1883 and
director of the Municipal Hospital at Friedrichshain, Berlin, from 1886 to 1903
[38–40]. Fürbringer was appointed to the Geheimrat (Privy Medical Councilor) in
Berlin in 1890 and was a member of the Royal Medical College of the province of
Brandenburg from 1890 to 1921 [38, 39].
During a discussion on subphrenic abscesses, Fürbringer commented that:
The presence of a serous exudate in an upper and a purulent in a lower intercostal space on
puncture is a valuable nding for diagnosing a subphrenic pyothorax but is not pathogno-
monic. Redner observed the same in two cases on autopsy, which later revealed multilocu-
lar pleurisy. Critical in diagnosis is the aspiration of pus after the puncture needle has
passed the diaphragm or when the needle moves during respiration [41, p.288].
Thus, Fürbringer sign refers to the movement of the subdiaphragmatic portion of
the needle upward during inspiration and downward during expiration (Table10.1).
10.2.9 Bolognini Sign
Pirro Bolognini (1860–1918) was born in Bologna, Italy, and received his medical
degree from the University of Bologna in 1855 [42, 43]. He was appointed assistant
at the Major Hospital of Bologna and physician at the Condotta di Borgo, Panigale,
where he taught in the pediatric clinic in 1902 [42]. During World War I, he was a
medical lieutenant of the Italian Red Cross stationed at Rovigo and Bologna and
director of the Military Hospitals [43]. He was appointed colonel in Bari and inspec-
tor of the province of the department of the Red Cross [42, 44].
Bolognini served as director of the Civic Hospital, Rovigo, in 1913 [44]. He was
president of the Polesana section of the National Association of Hospital Doctors
and honorary president of the Order of Midwives. He was also the founder of the
Italian Society of Pediatrics [44].
As described by his colleague:
He was a man of great ingenuity, a good soul, endowed with profound culture. He leaves
some valuable works in general medicine and pediatrics. He was generally loved and
esteemed [42, p.209].
10.2 Eponymic Signs
316
Bolognini described in 1895 a nding occurring in patients during the prodromal
phase and disappearing with the onset of the cutaneous eruption in measles. He
emphasized that during the maneuver, the physician should attempt to calm the
patient to avoid abdominal muscle contraction:
The patient is placed in a supine position with the thighs exed to relax the abdominal
muscles. Place the hands on the abdomen using the three middle ngers, alternate between
the hands light touch followed by increasing pressure. A tactile thrill is felt, giving the
impression that rubbing is occurring under the ngers, slightly produced by two rough
surfaces sliding over each other. The sensation is not uniform throughout the abdomen and
is only detectable in specic abdominal regions. Sometimes the rubbing is restricted to a
specic point on the abdomen. The rubbing may be present for only a brief period. It is dif-
cult to reproduce the phenomenon where it was previously found. In order to prolong the
detection of this nding, especially for those performing this maneuver for the rst time, it
is recommended that only slight pressure be initially applied because by applying increas-
ing pressure, the sensation will disappear [45, p.111].
Bolognini reported that the nding was present in 198 of 200 children examined
with measles.
He postulated that the nding was caused by an exanthema on the serosa of the
visceral and parietal peritoneum. Thus, Bolognini sign refers to the presence of a
tactile thrill over the middle nger in patients with peritoneal inammation caused
by measles (Table10.1).
10.2.10 Cushing Sign
Harvey Williams Cushing (1869–1939) was born in Cleveland, Ohio, USA, and
received his medical and master’s degrees from Harvard Medical School in 1895
with cum laude [46, 47]. He was a surgical house staff at Massachusetts General
Hospital from 1895 to 1896 and subsequently at Johns Hopkins Hospital under the
aegis of William S. Halsted (1852–1922) from 1896 to 1900 [46–49]. He studied
abroad at the physiology laboratories of Emil Theodor Kocher (1841–1917) and
Hugo Kronecker (1839–1914) in Berne, Switzerland, and Charles Scott Sherrington
(1857–1952) in Liverpool, England. Upon his return to Johns Hopkins, he estab-
lished the Hunterian Laboratory in honor of John Hunter (1728–1793) from 1900 to
1912 [46–48]. He was appointed associate professor of neurosurgery in 1903,
ascending to the rank title of Moseley professor of surgery at Harvard Medical
School and surgeon-in-chief at Peter Bent Brigham Hospital in 1912 [46–48, 50].
He served during World War I, initially with the French Army at the American
Ambulance Hospital, Paris, at the United States Base Hospital No. 5 from 1917 to
1919, neurosurgery consultant to the Royal Army Medical Corps, Camiers and
Boulogne, and subsequently, the medical headquarters of the American
Expeditionary Force [46–48].
After mandatory retirement, he accepted a position as Sterling professor of neu-
rology at Yale University from 1933 to 1937 and subsequently as director of studies
in the history of medicine [46–48, 50].
10 Intra-Abdominal andDiaphragm Signs
317
He founded the Society of Neurological Surgeons [48]. Among his many awards
and accomplishments, he received the United States Distinguished Service Medal,
from Great Britain; the Order of Companion of Bath; and France, ofcer of the
Legion of Honor, for his service during the war [47, 48]. He received numerous
honorary degrees, including the Doctor of Science and Law. Notably, he was elected
an honorary fellow of the Royal College of Physicians, London, and the Royal
College of Surgeons, England, in 1917 [46, 47]. He received the Cameron Prize
from the University of Edinburgh in 1924 and Lister Medalist from the Royal
College of Surgeons, England, in 1930. He was elected president of the American
College of Surgeons in 1922, the American Neurological Association in 1923, and
the American Surgical Association in 1927 [46, 47].
As to his character as described by MacCallum:
In Harvey Cushing everyone recognized a person of brilliant intellect and of great personal
charm. His inuence upon all who came in contact with him was deep and inspiring and
especially to his students and associates this had a lasting effect upon their lives. His
extreme and rigid dominance over his assistants during his operations was only part of his
care for the welfare of his patients and throughout the course of their illness under his super-
vision his devotion to their every comfort and attention to their slightest needs for the sake
of their successful recovery was part of his profound interest in their good [47, p.53].
As described in an editorial:
Essentially an aristocrat and a perfectionist, he always evinced the highest sense of obliga-
tion to his profession, and if his critical attitude, which tolerated nothing but the best, was
difcult for some colleagues from time to time it was magnicently good for the world at
large. Imbued with great vitality and enormous energy, he became the foremost surgeon of
his day, a master-teacher, a profound and prolic investigator, and the most accomplished
medical writer in our country [49, p.623].
Among his many accomplishments and contributions to medicine and surgery, his
name is undoubtedly best known in association with pituitary dysfunction or
Cushing disease.
Cushing described a nding occurring during the early stage of typhoid fever:
A sudden acute onset of increased abdominal pain is an all-important symptoms which
unfortunately may be absent or owing to a patient’s stupor be overlooked. Any complaint of
pain, however, of less abrupt onset, associated with tenderness, must arouse the greatest
suspicion on the part of the attendant. I cannot but believe that the condition which has been
spoken of above as a pre-perforative stage of ulceration often exists. A little localized
inammation of the serosa, with or without the passage of microorganisms and leading to a
slight adhesive peritonitis, usually of omentum, can give rise to these symptoms and pro-
duce an associated slight leucocytosis. This is precisely analogous to what occurs in the
pre-perforative stage of appendicitis, which, however, is of less urgent nature because in the
case of appendix which is xed and does not move about freely in the general cavity, as do
the coils of ileum, the adhesions are less likely to be dislocated and a general peritonitis,
which would result from this separation, is avoided [51, p.266].
Thus, Cushing sign refers to sudden non-xed pain in the abdomen during the pre-
perforation stage of small bowel perforation (Table10.1).
10.2 Eponymic Signs
318
10.2.11 Strauss Sign
Hermann Strauss (1868–1944) was born in Heilbronn am Neckar, Germany, studied
medicine at the Universities of Würzburg and Berlin, and received his doctorate in
Berlin in 1890 [52–54]. In 1893 he worked at the Medical University Hospital, and
from 1895 to 1906, he served as a senior physician at the Berlin University
III.Medical Clinic of Charité, Berlin [52]. At Kaiserin-Augusta Hospital in Berlin,
Strauss trained and conducted digestive physiology research with Carl Anton Ewald
(1845–1915) at the Medical University Clinic in Giessen under the auspices of
Franz Riegel (1843–1904) from 1893 to 1895 [53, 54]. He was appointed assistant
and senior physician at the III.Medical Clinic and polyclinic at Charité, Berlin,
under Hermann Senator (1834–1911) from 1895 to 1905 [53, 54]. Strauss habili-
tated with the medical faculty at the Friedrich Wilhelm University of Berlin in inter-
nal medicine in 1897 and was appointed a professor extraordinarius at the University
of Berlin from 1902 to 1934. He was relieved of all ofce duties, prohibited from
teaching, and had his medical license revoked under National Socialism in 1938
[53–55]. In 1906, he established a private polyclinic and, in 1910, served as chief
physician of internal medicine at the Jewish Hospital in Berlin. Beginning in 1910,
he served as director of the Department of Internal Medicine at the Jewish Hospital
in Berlin and was appointed to the Privy Medical Council [53]. The Gestapo
deported him to the Theresienstadt ghetto, Terezin, in 1942 [53, 56]. Here he was a
member of the Council of Elders and head of the science committee in the concen-
tration camp’s health care service [53].
Among his many outstanding accomplishments, he developed an intravenous
venous cannula (Strauss cannula) in 1898, introduced a low-salt diet to treat renal
insufciency, and designed the Strauss proctosigmoidoscope for examination of the
rectum and sigmoid in 1903 [52, 53]. He was appointed head physician in the
Department of Internal Medicine at the Jewish Hospital in Berlin from 1910 to 1942
[53]. Among his other accolades, he served as congress president of the Hufeland
Society for Digestive and Metabolic Disease and was decorated with the Iron Cross
for his service to his country during World War I [56]. He was co-editor of Archiv
für Verdauungs-Krankheiten (Digestive Diseases Archives) in 1910 [53].
In his discussion of an operative case of carcinoma of the stomach, Strauss
remarked:
Carcinoma metastases were found in the liver, retroperitoneal tissue, and Douglas pouch;
the latter was the site where we repeatedly found metastases. Consideration should be made
to investigate this site because it is commonly found and readily accessible for digital
exploration [57, p.584–585].
In 1899 he again spoke of a diagnostic method for detecting metastatic gastric car-
cinoma in cases where pathognomonic symptoms are absent:
I have already pointed out earlier that it is possible to detect cancerous nodules in the
Cavum Douglasii as an early or sole metastasis in isolated cases. In the meantime, I have
again observed two cases of this kind, of which one was of particular interest because only
10 Intra-Abdominal andDiaphragm Signs
319
by the detection of metastases in Douglas’ space could the differential diagnosis be made
between gastric ulcer and carcinoma ventriculi (ex ulcere natum) [58, p.874].
Thus, palpating a mass in the pouch of Douglas during a rectal exam suggests meta-
static gastric carcinoma (Table10.1). We are unaware of any studies evaluating this
sign’s sensitivity or specicity.
10.2.12 Landau Sign
Leopold Landau (1848–1920) was born in Warsaw, Poland, and studied medicine at
the Universities of Breslau, Würzburg, and Berlin and received his medical degree
from the University of Berlin in 1870 [59, 60]. He was an assistant surgeon during
the Franco-Prussian War from 1870 to 1871. He habilitated and was an assistant to
Otto Spiegelberg (1830–1881) at the clinic for gynecology and obstetrics at the
University of Breslau in 1872 and became an associate professor in 1874 [59–62].
He was a faculty member at the University of Berlin in 1876, titular professor in
1893, appointed as the Privy Medical Councilor in 1895, and an assistant professor
in 1902 [59–62].
Landau was elected member in 1894, deputy chairman in 1919, and an honorary
member of the Berlin Medical Society in 1918 [60, 62]. He served as an alderman
of Berlin’s City Council in 1901 and founded the Berlin Academy for the Science
of Judaism [59, 60, 62].
As to his character:
A very popular academic teacher, he has trained many students over the years who have
taken his teachings around the world. Despite his great practical and scientic activity, he
always found time to participate in the social endeavors of doctors. A rich, industrious life
came to an end with the death of Leopold Landau. But what he created will remain in our
science for all time [61, p.128].
Landau described a novel sign for the early detection of ascites in females
(Table10.1, Fig.10.1):
The sign consists of the inability to grasp the uterus in the usual or pathognomonic way,
even with a small amount of free uid. With the patient in a horizontal position, the ngers
of the two palpating hands do not meet on the sides of the uterus. The slightly depressed
uterus feels to the palpating ngers as if it were lying on a cushion of air or water. If the
patient is examined with the pelvis elevated and the abdominal wall relaxed as much as
possible by adduction of the thighs and exion of the knees bimanual examination provides
a different result. Now the ngers meet on the side of the uterus so it can be grasped. The
ndings on bimanual palpation have entirely changed since the uid directly ows toward
the diagram when the pelvis is elevated [63, p.1202].
Thus, Landau sign refers to the method for identifying ascitic uid in the abdomen
in women.
10.2 Eponymic Signs
320
Fig. 10.1 Landau sign (by Ryan Yale)
10.2.13 Lennander Sign
Karl Gustaf (Gustav) Lennander (1857–1908) was born in Kristianstad, Sweden,
and received medical training at the University of Uppsala and Karolinska Institute
and Seramerlasarettet (Seraphim Hospital), Stockholm [64, 65]. He served as an
associate professor in surgery and obstetrics at the University of Upsala, Sweden, in
1888, was appointed professor of surgery at the University of Uppsala in 1891, and
subsequently chief surgeon of the Uppsala Hospital [64, 65].
Lennander was an honorary fellow of the Royal College of Surgeons in 1900 and
recipient of the Doctor of Law from the University of Edinburgh [64–66]. Among
his many awards and honors, he was a member of the Swedish Academy of Science,
Science and Academy Society of Gothenburg in 1902, and the Royal Academy of
Sciences in 1905.
As to his character:
At Uppsala and in his operating theatre, one came to know the man fully. Of medium height
and gure, his head rst caught the eye and called forth admiration of its massive powerful-
ness. Brusque in manner and careful of words, he lacked the polish of the Swede and
reminded one somewhat of the Norwegian type of Scot. The testimony of his patients
showed that he never lacked kindliness and consideration. (…) He was a good teacher, and
his clinic was always well attended [64, p.1086].
Lennander observed in patients with peritonitis (Table10.1):
A large number of diffuse as well as circumscribed infections of the peritoneum during their
course occur without elevation of temperature. Usually, however, there is a temperature
elevation. In order to detect it with certainty, the temperature must be measured in the rec-
tum. In fact, the axillary temperature is often abnormally low. The difference between the
temperature in the rectum and the axilla, which under normal conditions is about 0.6°C,
10 Intra-Abdominal andDiaphragm Signs