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can be much greater in peritonitis. As a rule, the larger it is, the worse the patient’s general
condition when the temperature is taken. A large difference in temperature between the
rectum and axilla is, in most cases, is due to collapse with feeble blood ow in the skin, not
infrequently in conjunction with profuse sweating (“cold sweat”). It is not uncommon for
the difference to be 2-3 times or more degrees when death is imminent. Simultaneous mea-
surement in the axilla and the rectum can therefore be of great importance from a prognos-
tic point of view. (…) Even an insignicant rise in temperature can be of great diagnostic
importance. If you suspect organ perforation and diffuse peritonitis without having a clear
picture, you must measure it every hour. In such cases, an increase in the temperature of the
rectum by a few tenths of a degree and increasing sensitivity to pressure on palpation from
the rectum establish the diagnosis of diffuse peritonitis [67, p.35–36].
As stated by Propping:
It is known that Madelung was the rst to point out that one could diagnose peritonitis by
comparing the temperature of the axilla with that of the rectum. The difference in suppura-
tive peritonitis is always greater than normal and can even go up to 1.5°. Considering the
extreme importance of a symptom with such reliability, the often-difcult diagnosis of peri-
tonitis can be established with certainty. However, no agreement has yet been reached, and
there has been no conrmation of this temperature change. While Lennander in 1893
regarded the abnormal temperature difference as pathognomonic for purulent peritonitis
with exudation in the lower part of the abdomen, he also found in 1901 that the difference
between the rectal and axillary temperatures was not frequently signicantly greater than
usual [68, p.506].
Thus, Madelung and Lennander sign srefer to the difference between the axillary
and rectal temperatures in peritonitis.
10.2.14 Bryant Sign
John Henry Bryant (1876–1906) was born in Ilminster, Somerset, England, and
received his bachelor of medicine and bachelor of science degrees from Guy
Hospital in 1890 with the distinction of earning rst-class honors, a gold medal in
medicine, rst-class honors in forensic medicine, and a medical degree in 1891
[69–71]. He was appointed house physician and resident obstetric assistant, elected
medical register from 1892 to 1898, and subsequently assistant physician to Guy
Hospital [69–71]. Bryant was appointed demonstrator of morbid anatomy in 1899
and lecturer on materia medica and therapeutics in 1903. He was the co-editor of
Guy’s Hospital Reports [69–71]. He received fellowship in the Royal College of
Physicians in 1901 [69].
As to his character:
As a physician the same conscientious care and thoroughness characterized his work in all
departments. In the investigation of cases his systematic method enabled him often to
come to denite conclusions where haphazard work would have signally failed. His
knowledge of the world too, was not the least of his assets as a consultant enabling him at
all times to take a human interest in his patients quite apart from their professional aspect.
It was no doubt this trait in his characters which endeared him to patients, for although, a
man of few words, he had a large fund of sympathy, which showed itself in many small
unostentatious ways. (…) Always strenuously opposing deceit in any form, he said freely
10.2 Eponymic Signs
322
what he thought, perhaps sometimes to his own detriment, and he always pursued the
course which he considered right. It would be hard to nd a man of more upright character,
who ran straight at all times, and thus endeared himself to everyone who really knew him
[69, p.1319].
Bryant described a series of patients with abdominal aortic aneurysms. He
reported:
In one case blood was effused into the right spermatic cord, and the corresponding half of
the scrotum was much ecchymosed [72, p.75]. When blood is extravasated into the anterior
abdominal wall ecchymosis may appear, and in one case which I have already mentioned,
in which blood was effused into the spermatic cord, the scrotum on the same side became
much ecchymosed [72, p.79].
Thus, Bryant sign refers to scrotal ecchymosis caused by intra-abdominal hemor-
rhage (Table10.1).
10.2.15 Morel Sign
There is limited historical information on Louis Morel (1876–?). He was an intern
at the Hospitals of Paris in 1904, appointed agrégé in 1926, and was a professor at
the Faculty of Medicine, Toulouse, France [73–75].
Morel described an observation found in a patient with intraperitoneal rupture of
the bladder:
We noticed a second peculiarity: instantaneousness engorgement of the bladder, which
should be sought in the following way: The wounded lying down is probed; the catheter
brings back a certain amount of urine and empties the bladder. The injured person is then
asked to stand and remain upright for a few minutes. He is then put back down and probed
a second time. The bladder lls again through the intraperitoneal effusion with a quantity
equal to the rst evacuation withdrawn. This observed nding occurs because the urine,
which leaves the bladder freely through the ruptured bladder, reenters it with the same
capacity and manner as to ll the urinary reservoir with urine collected in the small pelvis
by standing. The urine collects in the iliac fossae and between the intestinal loops [74,
p.809–810].
Thus, Morel sign refers to intraperitoneal uid lling the bladder in the standing
position after the bladder is emptied in bladder rupture (Table10.1).
10.2.16 Kehr Sign
Johannes Otto Kehr or Hanes Kehr (1862–1916) was born in Waltershausen,
Thuringia, Germany, and received his medical training in Freiburg, Halle, Berlin,
and Jena, and his medical degree from the latter in 1885 [76, 77]. He was appointed
assistant to Ernst Meusel (1843–1914) in Gotha and continued his surgical training
with Eduard Albert (1841–1900) and Theodor Billroth (1829–1894), earning the
10 Intra-Abdominal andDiaphragm Signs
323
Specialist for Surgery and Orthopedics degrees in 1888. He was a surgeon in a pri-
vate clinic in Halberstadt, a professor in 1895, and a privy councilor in 1905. He
later moved and worked at the private clinic of Ernst Unger (1875–1938) in Berlin
in 1910 [76, 77]. In 1913, he published his two-volume book Die Praxis der
Gallenwege Chirurgie in Wort und Bild (The Practice of Bile Duct Surgery in Words
and Pictures) [78]. His most signicant contributions were in the surgical manage-
ment of gallbladder and biliary diseases.
Kehr sign has traditionally been described as pain in the left shoulder associated
with splenic rupture. Klimpel, in a review of the literature, found a lack of compel-
ling evidence that this sign should be attributed to Johannes Otto Kehr (1862–1916)
[79]. We found on the contrary, upon further review of the literature, that Kehr
stated in his discussion on splenic rupture in Handbuch der praktischen Chirurgie
(Manual of Practical Surgery):
There is no pathognomonic symptom for injuries to the spleen. In contusions, pain and
enlargement of the spleen are typical symptoms. When rupture occurs, all other signs and
symptoms of internal bleeding are less critical. In subcutaneous injury, the affected person
usually experiences pain, initially on the left side, quickly spreading to the entire abdomen.
The signs of collapse (pronounced pallor, small pulse, feeling cold and faint) appear. In rare
cases, the injured person does not experience anything from splenic rupture, and collapse
may not be present. Left shoulder pain is not common. Other manifestations involve the
lungs, heart, and larynx (hoarse voice up to complete lack of voice). The latter indicates an
alteration of the vagus involving the splenic plexus through the semilunar ganglion [80,
p.689].
Levy referenced Kehr’s publication on splenic injuries and left shoulder pain symp-
toms and presented the case of a 29-year-old man with internal hemorrhage second-
ary to splenic injury and severe left shoulder pain, emphasizing its diagnostic
signicance [81].
Interestingly, Kehr, in his book Introduction to the Differential Diagnosis of the
Separate Forms of Gallstone Disease, described a patient with recurrent cholecysti-
tis or cholangitis (accompanying inammatory jaundice), adhesive peritonitis, and
adhesions between the gallbladder and omentum or colon, and “with this several
attacks of colic and inammation in the left-shoulder-joint” [82]. He also reported,
“The pain of gallstone colic is more to the right and localized in the gallbladder
region, whence it frequently radiates to the back, and the right should blade and
breast” [82].
A study by Lowenfels (1966) showed that nine out of ten patients with splenic
rupture had a positive Kehr sign at presentation [83]. Studies reported this sign in
patients with splenic abscess, spontaneous phrenic artery rupture, infectious mono-
nucleosis, and following colonoscopy [84–90]. Irritation of the diaphragm by the
abdominal contents, including free blood, results in the transmission of pain sensa-
tion through the phrenic nerve to the C3-C4 nerve roots. The supraclavicular nerve
supplying the left shoulder shares the origin with the phrenic nerve innervating the
diaphragm; thus, pain is referred to as the left shoulder [83, 84]. There are no studies
that dened the sensitivity and specicity of this sign.
Thus, Kehr sign refers to pain in the left shoulder in splenic rupture (Table10.1).
10.2 Eponymic Signs
324
10.2.17 Barnard Sign
Harold Leslie Barnard (1868–1908) was born in Highbury, London, England, and
received his bachelor of medicine degree from the University of London with rst-
class honors; fellowship from the Royal College of Surgeons of England in 1895;
and master of science degree in 1896 [91–94]. He was appointed sequentially as
senior dresser to outpatients, receiving room ofcer; house physician, and house
surgeon at the London Hospital to Drs. Samuel Fenwick (1821–1902) and Edwin
Hurry Fenwick (1856–1944), respectively; surgical registrar in 1897; assistant dem-
onstrator of anatomy; demonstrator of physiology to Leonard Hill (1866–1952) in
1897; and surgical tutor in 1899 [91–93].
He held a full-time staff appointment and was an assistant at the surgical ofce
at the Metropolitan Hospital until 1900, followed by serving as a surgical tutor at
the London Hospital from 1900 to 1904. His last position was demonstrator of sur-
gical pathology and surgeon in charge of outpatients at the London Medical School
and Hospital in 1907 [91–93].
His character as described by Hill:
Mr. Barnard was a man of enormous mental energy, which continually carried him beyond
his bodily strength. His enthusiasm for his profession, his untiring zeal, have I fear led to
the great loss we have sustained by his early death. He was a man possessed with the simple
faith of living a life devoted to his work and the search after truth, and his great spirit has
overdriven a body too frail for the tasks he set it [91, p.539].
With Leonard Hill they described the armlet method of determination of blood pressure
by the sphygmomanometer, the technique simultaneously described by Riva Rocci [94].
Barnard dened the clinical features of a subphrenic abscess:
The abdominal swelling formed by a subphrenic abscess does not descend on respiration,
because it is adherent. The part of the swelling formed by peritoneal adhesions is rigid,
tender, and dull on percussion. The part formed by pus in contact with the abdominal wall
is scarcely tender, bulges and uctuates, and is dull on percussion [95, p.432].
In his description of the temperature:
Pyrexia was always present. As a rule, it was low (100 to 101), sustained and rocked night
and morning. In several cases, however, it frequently reached normal, and was never above
100 F.These cases were well localized or had ruptured into the stomach or intestines. On
the other hand, in the diffuse and a cause stages temperatures as high as 104 to 105 F, were
often recorded [95, p.431].
Thus, Barnard sign refers to the absence of pain and hectic temperature in some
patients with subphrenic abscesses (Table10.1).
10.2.18 Blumer Sign
George Blumer (1872–1962) was born in Darlington, County Durham, England, and
received his medical degree from Cooper Medical College (Leland Stanford
University), San Francisco, in 1891 [96–99]. He completed an internship at San
10 Intra-Abdominal andDiaphragm Signs
325
Francisco City and County Hospitals and became a surgical ofcer and house ofcer
while conducting postgraduate work in bacteriology and pathology at Johns Hopkins
Hospital until 1893. He was appointed assistant to the surgical staff under William
Stewart Halsted (1852–1922) and then Sir William Osler (1849–1919) from 1893 to
1895, followed by an assistantship in the Department of Pathology under William
Henry Welch (1850–1934) from 1895 to 1896 [96–99]. He was director of the
Bender Hygienic Laboratory in Albany, NewYork, from 1896 to 1903 [96, 100].
He served on the faculty initially as an adjunct professor, followed by a professor
of pathology and bacteriology at Albany Medical College until 1903 [99]. While in
Albany, he also maintained positions as a pathologist at St. Peter’s and Childs’
Hospitals, Cohoes Hospitals in Cohoes, NewYork; Troy and Samaritan Hospital in
Troy, NewYork; and director of the Bureau of Pathology and Bacteriology for the
NewYork State Board of Health [98].
He was an associate professor of pathology at Cooper Medical College San
Francisco from 1904 to 1905 and an assistant in the medical schools at the University
of California from 1905 to 1906 [98, 99]. Blumer was appointed the John Slade Ely
professor of theory and practice medicine from 1906 to 1910 and subsequently dean
of the Yale Medical School beginning in 1910 and named the David P.Saith profes-
sor of clinical medicine at Yale University Medical School in 1920. He was the
director of the New Haven Hospital and Dispensary [96–99].
In a paper read before the Troy and Vicinity Medical Association on April 6,
1909, Blumer reported:
The sign which I wish to bring to your attention is one which I have been observing for the
past two or three years. It is not, as I shall presently show you, a new sign, but for some
reason it seems never to have gotten into the textbooks, and scarcely at all into the periodi-
cal literature. I prefer to call it the rectal shelf because that best describes its feel [101,
p.362–363]. (…) It is evident from these observations that under certain conditions malig-
nant neoplasms within the abdomen metastasize to Douglas pouch and that in certain
inammatory conditions of an infectious nature the infective agent may set up marked
localized changes in the same region. (…) The effect of this malignant or inammatory
inltration of Douglas’ cul-de-sac is the formation of the palpable rectal tumor which I have
described as the rectal shelf [101, p.363].
Blumer described the method for examination of the rectal shelf:
If one passes the nger into the rectum in these cases the lower portion of the bowel is usu-
ally normal, it is not until the prostate gland has been passed that any abnormality is
detected. Just above the prostate in some cases, in others at the limit of palpability, 2 to 4cm
above, if the nger is passed along the anterior rectal wall it impinges upon a shelf of almost
cartilaginous feel which projects into the rectal cavity. In some cases, further palpation
shows that the whole rectum is involved in an annular zone of inltration more marked
anteriorly and tapering off toward the posterior wall, a signet ring stricture, as Schnitzler
calls it. In such cases the inltration is no longer conned to Douglas’ pouch but has
involved the submucosa of the rectum in which the new formation may spread quite widely.
The inltrated area is more or less xed, it is shelf-like or peg-like, at the most prominent
portion, and there is no ulceration of the mucous membrane over it. The lack of ulceration
of the overlying mucosa, together with the peculiar shape, is what distinguished the rectal
shelf from a primary rectal neoplasm [101, p.364–365].
Thus, Blumer sign refers to the palpable, xed, rectal shelf signifying a malignant
or inltrative process occurring at the pouch of Douglas (Table10.1).
10.2 Eponymic Signs
326
10.2.19 Brown Sign
Alfred Jerome Brown (1878–1960) was born in NewYork, USA, and studied medi-
cine at the College of Physicians and Surgeons of Columbia University (currently
Columbia University Vagelos College of Physicians and Surgeons) in 1903 [102–
105]. He completed an internship at Presbyterian Hospital, NewYork City, from
1903 to 1905 and was an assistant in surgery at Columbia University College of
Physicians and Surgeons. This was followed by appointments as surgical director of
the rst surgical division at Columbia University Division of Bellevue Hospital,
NewYork, and assistant at Presbyterian Hospital and Vanderbilt Clinic Dispensaries
[103, 104]. Brown was a visiting surgeon at NewYork and New Jersey Orthopedic
Hospitals, assistant surgeon lieutenant junior grade rst battalion in 1906, and assis-
tant in anatomy in 1909 [104–107].
During World War I, Brown was an instructor in the War Department Surgeon
General’s Ofce and major in the United States Army as chief of the surgical ser-
vice at Debarkation Hospital in Staten Island, NewYork, and the Base Hospital at
Brest, France, chief of surgical services and consulting surgeon from 1917 to 1919
[102, 104].
Brown was appointed assistant professor to the College of Medicine at the
University of Nebraska in 1919 and was a professor of surgery from 1934 to 1943
[102, 105]. He was also a division, district, or local surgeon to four railroads and a
physician to the Federal Security Board of the United States and Civil Service
Commission [104].
Brown was president of the Western Surgical Association, Omaha-Douglas
County Medical Society, and Omaha Midwest Clinical Society. He was a member
of many other surgical and medical societies and organizations [104, 105].
His character as described by R.R.Best:
Dr. Brown was the author of many articles in the eld of general surgery and frequently
these publications as well as basic statements on the embryology or anatomy pertaining to
the subject. Students, internes, residents, and younger surgeons had a tremendous admira-
tion for and remembrance of this quality, so readily noted in lectures, conferences and dur-
ing ward rounds. His memory was phenomenal and once he saw, read, or heard, he never
forgot. In spite of this mass of information pertaining to history, anatomy and embryology,
he was not one to take the oor at a meeting and relate his knowledge, and he seldom openly
criticized or corrected a misstatement by others [104, p.348].
Brown identied and described two signs occurring in patients with intestinal per-
foration secondary to typhoid fever:
The rst sign, for want of a better description, I have designated as the “dipping crackel”
sound. At the rst examination, which took place a few minutes after the perforation on
placing the bell of the stethoscope over the right iliac fossa and dipping suddenly with it as
in dipping palpation, a very ne crackle was heard which sounded much like a ne crepitant
rale, or as if two sticky surfaces were being drawn apart. It seems to be due to the fact that
in dipping suddenly the parietal and visceral layers of the peritoneum come in contact for
an instant and apparently, the inamed surfaces stick together for a moment and then pull
10 Intra-Abdominal andDiaphragm Signs
327
apart. I have never found this sign present over an area of more than two inches in diameter
and never later than four hours after the initial symptoms, presumably because the accumu-
lated gas prevents the surfaces from coming in contact [108, p.695].
The second sign involved the following:
The patient was examined immediately, and a small area of tenderness found low down in
the right iliac fossa. He was turned on his left side and in half an hour the areas of tender-
ness had moved toward that side about two inches [108, p.695]. (…) The explanation of the
sign is simple. At the time of perforation there is a greater or lesser amount of the contents
of the intestine extruded into the peritoneal cavity, and this extravasation tends to ow in the
direction of least resistance, that is, downward, and its extension is marked by the indication
of local peritonitis, pain, tenderness, and rigidity. By turning the patient over on the unaf-
fected side that side is made the lowermost, and if there be a perforation with extravasation
the sign of the extension of the local peritonitis will pass to that side which is lowermost
[108, p.696].
Thus, Brown sign refers to the auscultatory “dipping-crackle” sound in acute peri-
tonitis and tenderness found in the lower right iliac fossa, extending approximately
2in. to the left when the patient is turned toward the left side (Table10.1).
10.2.20 Chilaiditi Sign
Demetrius Chilaiditi (1883–1975) was born in Vienna, Austria, and received his
medical degree from the University of Vienna in 1908 [109, 110]. He worked as an
internist and radiologist at the III.Medical University Clinic and Central Roentgen
Institute in Vienna. He moved to Istanbul, Turkey, where he established a Radiologic
Institute and co-founded the Turkish Radiological Society [109, 110].
Chilaiditi reported three cases, as conrmed uoroscopically and on X-ray,
where there was partial temporary displacement of the liver from the dome of the
diaphragm as a result of the interposition of the transverse colon between the liver
and dome of the diaphragm:
The type and severity of displacement vary depending on the quantity and degree of disten-
sion of the interposed loop of the bowel and secondarily on the behavior of the hepatic liga-
ments. During the displacement, there were no symptoms or dysfunction of the relevant
organs, and the patient could not detect the transition. The change in the shape of the liver
during displacement and the assumption of a normal shape during reduction can be
explained by the softness, the plasticity, and the changing blood content invivo, which can
also be seen in the X-ray images but is particularly evident during uoroscopy. The percus-
sion ndings usually, but only sometimes, coincide with the X-ray ndings. The palpation
nding is sometimes uncertain, especially when bowel loops are in front of the edge of the
displaced liver. (…) The term hepatoptosis or wandering liver for this type of displacement
needs to be specied insofar as it is a ptosis in the narrower sense, in contrast to the much
larger number of cases of hepatoptosis in which the liver does not give up its direct contact
with the diaphragm or can speak of an interposition ptosis (insofar as certain organs inter-
pose between the liver and the diaphragmatic dome). One could also refer to this condition
as a “wandering liver.” If used, the term should not be interpreted as having the same mean-
ing as hepatoptosis (which is what most authors are currently doing). The wandering liver
10.2 Eponymic Signs
328
would, therefore, only constitute a relatively rare form of hepatoptosis. The liver displace-
ment is partial in all three cases since, even with severe displacement, the median parts of
the liver remain in direct contact with the diaphragm to varying degrees, despite possible
damage to all the ligaments. This partial ptosis does not become total because of the more
resistant attachment of the median parts of the liver, the physically explicable behavior of
the intestine pushing off, and the nature of the liver tissue, which protects the median xa-
tion apparatus. Even if the ligamentous attachments are damaged, the ptosis can remain
partial [111, p.205–206].
Thus, Chilaiditi sign refers to the interposition of the transverse colon between the
liver and diaphragm (Table10.1).
10.2.21 Oehlecker Sign
Franz Oehlecker (Öhlecker) (1874–1957) was born in Hamburg, Germany, studied
medicine in Leipzig, Tübingen, Kiel, Berlin, and Strasburg, and received his medi-
cal degree in 1901 [112, 113]. He was an assistant physician at the Pathological
Institute from 1902 to 1903, Friedrichshain City Hospital from 1903 to 1905, and a
scientic assistant at Imperial Health Ofce in Berlin-Dahlem, conducting research
on tuberculosis from 1905 to 1907 [112]. He trained in surgery under the tutelage of
Wilhelm Körte (1853–1937) in Berlin and Hermann Kümmell (1852–1937) at the
University Hospital of Eppendorf, Hamburg. He was a senior physician in the I. sur-
gical department of Hamburg-Barmbek General Hospital from 1914 to 1947 [112,
114]. Oehlecker was an associate professor in 1923 and a professor in 1931 at the
University of Hamburg [114].
He is best recognized for devising a direct method to determine blood compati-
bility for blood transfusion (Oehlecker test) [112]. He was a member of the German
Society of Surgery in 1957 [115]. An award medal has been named for Franz
Oehlecker by the German Society for Transfusion Medicine and Immunohaematology
[116]. He was elected an honorary member of the German Society for Blood
Transfusions at the fth Conference in Bochum in 1955 [114]. Oehlecker is also the
recipient of the Federal Cross of Merit and an honorary doctorate from the Faculty
of Natural Sciences at the University of Hamburg [114].
Oehlecker’s name should not be used in medical discourse to describe his sign or
test because he signed the Confession of German professors declaring loyalty to
Adolf Hitler in 1933. He was a member of the National Socialist German Workers’
Party and was involved in forced male sterilization [117].
Oehlecker reported his experience of left or right shoulder pain in various acute
intra-abdominal diseases:
Shoulder pain is triggered not only by inammatory processes but also by mechanical stim-
uli involving phrenic nerve endings. Irritation of the phrenic nerve endings causes shoulder
pain not only on the convexity of the liver but also on the diaphragm and the area supplied
by the phrenic-abdominal rami. If the disease is in the abdominal cavity, and we observe
right or left shoulder pain, we can conclude that the disease process, which can be quite
different, occurs near the diaphragm. In many cases, the shoulder symptom is overlooked.
10 Intra-Abdominal andDiaphragm Signs
329
The patient, like the doctor, often attaches no importance to the pain in the shoulder; some-
times, it is regarded and treated as rheumatism when it represents a distant symptom of the
phrenic nerve. The shoulder symptom is common in acute diseases of the abdomen and is
frequently overlooked because of the presence of severe symptoms and pain in the abdomi-
nal cavity [118, p.853–854].
Thus, Oehlecker sign refers to left or right shoulder pain caused by subdiaphrag-
matic inammation (Table10.1).
10.2.22 Claybrook Sign
Edwin Booth Claybrook (1871–1931) was born in Westmoreland County, Virginia,
USA, and received his medical degree from the University College of Medicine,
Richmond, Virginia. He co-founded the Allegheny General Hospital in Cumberland,
Maryland, where he practiced surgery [119, 120]. He was also a surgeon for the
Baltimore-Ohio (B&O) and Western Maryland railroads [120]. He was a member of
the Cumberland Board of Health, a fellow of the American College of Physicians,
and several societies, including the Southern Medical Society and Allegany-Garrett
Medical Society [120].
Claybrook described an auscultatory sign in patients who sustained intestinal
perforation. The sign:
[c]onsisted in the transmission of the heart and respiratory sound, so that they could be
heard all over the abdomen almost as well as over the chest. The ear was all that was needed
to elect the symptom, and if it was of any special value, it was doubly valuable on that
account, for often the very life of these patients depends upon the attitude of the doctor who
rst sees them [121, p.105–106].
Claybrook postulated that the sign was caused by sound transmitted by bowel con-
tent, blood, and urine in the abdominal cavity and irritating the parietal peritoneum.
The sign was absent in case of abdominal wall injury, extraperitoneal bladder rup-
ture, and a small hepatic rupture conned to the liver. It was present regardless of
whether the abdomen was rigid or soft. Claybrook erroneously believed that uid is
less effective for sound transmission than air or gas, and that its presence was an
indication for proceeding to an immediate laparotomy.
Thus, Claybrook sign refers to the transmission of heart and respiratory sounds
through the abdominal wall in cases of intestinal perforation (Table10.1).
10.2.23 Drachter Sign
There is limited historical information on Richard Drachter (1883–1936). Drachter
was an associate professor, followed by a senior surgeon in 1922 at the University
Children’s Hospital, Munich, where he served from 1914 to 1936 [122, 123]. With
Josef Rudolf Gossmann, he published the book Chirurgie des Kindesalters (Pediatric
10.2 Eponymic Signs
330
Surgery) in 1930. The Richard Drachter Prize for pediatric surgery is the highest
prize established by the German Society for Pediatric Surgery [124, 125].
Drachter described a maneuver for examining a child with suspected peritonitis
(Fig.10.2):
With the patient lying on his back, the examiner slightly raises one leg (the right one) by
gasping the front foot with the left hand with the knee extended. The sole of the right foot is
tapped lightly with the right st. When examining for peritonitis, we intend to use this tech-
nique to cause the visceral peritoneum to move, albeit minimally, against the parietal peri-
toneum and thereby induce pain in the presence of inammatory conditions in the abdomen.
An advantage of this examination method over others is that when it is performed, one can
separate oneself from the diseased part of the body, which only the patient can touch. (…)
If the patient suffers abdominal pain from the impact, or if previously existing pain suddenly
increases, the patient will express this in some way; This often happens—which is very
characteristic—by the child grasping the body with one or both hands. If there is no abdomi-
nal pain, or if the pain is not due to an inammatory condition of the peritoneum, a similar
pain sensation or increased pain from the impact does not occur [122, p.599].
Thus, Drachter sign refers to abdominal pain produced by tapping on the plantar
aspect of a child’s foot (Table10.1).
Fig. 10.2 Drachter sign (by Ryan Yale)
10 Intra-Abdominal andDiaphragm Signs