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10 Intra-Abdominal andDiaphragm Signs
357© 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_11
Chapter 11
Abdominal Wall Signs
11.1 Introduction
Imaging has been the mainstay in evaluating the etiology of abdominal pain. Chronic
abdominal wall pain is frequently incorrectly misattributed to visceral pain leading
to delayed diagnosis, unnecessary diagnostic testing, and high cost of medical care.
Signs of the abdominal wall are those that primarily or secondarily involve the
abdominal wall. They include the physical examination techniques of observation
and palpations. These signs provide clinical cues to an underlying disease process
occurring within the abdomen and the organ system. They are reported chronologi-
cally based on the date of their initial description.
11.2 Eponymous Signs
11.2.1 Auenbrugger Sign
Leopold Auenbrugger (1722–1809) was born in Graz, Styria, Austria, and studied
medicine at the University of Vienna under the aegis of Baron Gerard van Swieten
(1700–1772) [1–5]. He was a resident medical assistant and later physician at the
Spanish Military Hospital from 1751 to 1762 and Holy Trinity Hospital in 1753,
renamed the “United Hospital” in 1760 [1–5]. Auenbrugger was an associate physi-
cian in 1755 and an attending physician in 1761 [4].
Auenbrugger published his historical book Inventum Novum Ex Percussione
Thoracis Humani Ut Signo Abstrusos Interni Pectoris Morbos Detegendi (A New
Discovery that Enables the Physician from the Percussion of the Human Thorax, to
Detect the Diseases Hidden within the Chest) in 1761 [4]. The method of chest per-
cussion in clinical diagnosis was not initially well received or adopted by physicians.
358
It was Baron Jean-Nicolas Corvisart des Marets (1755–1821) who is credited for
translating Auenbrugger’s writing from Latin to French under the title Nouvelle
méthode pour reconnaitre les maladies internes de la poitrine par la percussion de
cette cavité (New Method for Recognizing Internal Diseases of the Chest by Percussion
of this Cavity). It was because of Corvisart that this method of physical examination
gained notoriety as an important tool in clinical medicine and physical diagnosis [3].
Auenbrugger spent the remainder of his career as a private practitioner and
developed a reputation for treating diseases of the chest [1, 4]. He was a member of
the court at Vienna and was conferred the title “Elder von Auenbrugger” by Josef II
for recognition of his public service and skills as a physician [4].
To gain some insights into his character, Clar wrote:
He was a tireless and undeterred as a doctor and full of goodness and philanthropy to his
last days; the bells went form the front door into his living room, and a small hand lantern
was always ready, with which he often used to light his way to the remotest suburbs on his
way to the sick at night. He was the most sought-after doctor of chest diseases [6, p. 29].
In the preface of Inventum Novum, the reader can further gain a glimpse of his pro-
found humility, sincerity, and careful investigation devoted to chest percussion:
What I have written I have proven again and again by the testimony of my own senses, and
amid laborious and tedious exertions; —still guarding, on all occasions, against the seduc-
tive inuence of self-love. (…) I think it is necessary candidly to confess, that there still
remain many defects to be remedied—and which I expect will be remedied by careful
observation and experiences [7, p.379]. In submitting this to the public, I doubt not that I
shall be considered, by all those who can justly appreciate medical science, as having
thereby rendered a grateful service to our art inasmuch as it must be allowed to throw no
small degree of light upon the obscure diseases of the chest, of which a more perfect knowl-
edge has hitherto been much wanted [7, p.380].
Under the twelfth observation of dropsy of the chest in Inventum Novum Auenbrugger
described the nding of “Swelling of the abdomen, more especially in the epigas-
trium and particularly in that point on which the incumbent water gravitates”
(Table11.1) [7, p.399]. Thus, Auenbrugger sign refers to abdominal swelling sec-
ondary to a pericardial effusion.
11.2.2 Rosenbach Sign
For historical information regarding Ottomar Rosenbach (1851–1907), see Chap. 7,
Liver and Biliary System Signs. We included for the interested reader additional
information describing his profound, extraordinary character:
As expressed by W.Guttmann:
He possessed a personality that was striking and extraordinary in every respect. He was not
only an excellent doctor, scholar, and researcher of lonely greatness but also a great noble,
a free and proud spirit, and a man of rare integrity and purity of character. All who were
fortunate enough to be among his friends and acquaintances looked up to him and held him
11 Abdominal Wall Signs
359
in the greatest reverence. Moreover, even from afar, only a few could escape the magic of
his personality. His penetrating mind and knowledge made him recognize all weaknesses,
whether abstract things or people he had encountered. He was of such extraordinary good-
ness, benevolence, and tenderness of sentiment that he, far from becoming a misanthrope to
all who approached him with a request, provided advice, comfort, and support. His power-
ful sense of justice always made him stand up for those who were weaker or poorly treated.
He could forgive everything, just not the oppression of others. (…) Unrelenting in severity
towards himself, he was full of consideration for others and always had understanding and
forgiveness for human weaknesses. Only in the eld of knowledge were there no compro-
mises for him. Here he defended what he recognized as true and correct with the most
extraordinary energy and, if necessary, with cutting edge, without regard to the personal
sensitivity of others and their advantage. Science was sacred to him. The courage with
which he, often alone, opposed the prevailing dogmas and trends on essential questions
(e.g., tuberculin, diphtheria serum, bacteriology, syphilis) when he considered them wrong
and disastrous was truly admirable [8, p. 5–6].
Rosenbach described the absence of the supercial abdominal reex in patients
with cerebral hemiplegia (Table11.1):
It is well known that stroking the abdomen produces a reex retraction. Based on the con-
traction of the abdominal muscles, these indentations can be induced on one side since the
skin stimuli do not cross the midline. The depression occurs most clearly when the nail is
quickly run over the abdominal surface, regardless of the direction of the stroke. Contact
with cold objects can also often produce the sign, but the stroke with the ngernails works
best. If the procedures described are applied to those with cerebral hemiplegia, no abdomi-
nal reex, as I would like to call the phenomenon, occurs on the paralyzed side. In contrast,
the same occurs promptly and unchanged on the healthy side. As mentioned above, the
failure of the abdominal reex is always present in patients with acute hemiplegia. If the
hemiplegia is subacute, the contraction occurs weakly. Even in chronic cases, a difference
on both sides of the body is observed, in these cases. As far as I can tell, it always remains
weaker on the diseased side [9, p.846].
Thus, Rosenbach sign refers to the absence of the abdominal skin reex in cerebral
hemiplegia.
11.2.3 Simon Sign
There is limited historical information on Jules Simon (1831–1899). He served as a
physician at the Hôpital des Enfants Malades (Hospital of the Sick Children) in
Paris throughout his career [10]. As to his character as described by Pierre Merklen:
To speak of his laborious life, his high professional capacity, and the value and success of
his teaching, is to repeat things known to all. Those who have seen him at work and have
had the pleasure of living in his intimacy can add that his grand notoriety was based on his
work and personal qualities [10, p.769]. Jules Simon had given himself entirely to medical
practice, sacricing pleasure and rest to it and nding joy only in the exercise of his profes-
sion. Endowed with a spirit of penetrating observation and open to all progress, with great
common sense, animated by a lively and convincing faith in the effectiveness of hygiene
and therapy, he inspired boundless condence in his patients and their families. He pleased
them with his attention full of solicitude, rened good nature, and often playful and pictur-
esque conversation [10, p.770].
11.2 Eponymous Signs
360
Simon described a nding occurring during the early phase of meningitis in chil-
dren (Table11.1):
I especially wish to insist on the disharmony, the dissociation of the movements of the dia-
phragm of the rib cage appearing from the rst days of meningitis. This nding reveals this
disease even in complex and misleading cases. (…) If you do not entirely bare the chest and
abdomen in the epigastric region, you will be unable to observe the sign I am showing. If
you are fortunate to examine a child with meningitis early in the disease course, hyperes-
thesia of the skin, brought into contact with the air, causes brief involuntary reex move-
ments of the chest and abdomen. Proceed slowly by rst observing the region of choice
covered with the child’s shirt. Gradually try to lift it, and put it back without jerks, and you
will nd yourself in the presence of a curious nding [11, p.250].
Simon sign is ascribed to two phenomena occurring in early meningitis. First, the
dyssynchrony between the diaphragm and thorax movements, and second, involun-
tary reex contraction of the chest and abdomen. Although not explicitly stated by
Simon, it is because of this dissociation of movement that the umbilicus remains
xed or retracted during inspiration [12].
11.2.4 Guinard Sign
Marie Aimé Désiré Guinard (1856–1911) was born in Saint-Étienne, France, and
studied medicine in Paris under the aegis of Aristide Auguste Stanislas Verneuil
(1823–1895) at La Pitié Hospital and Paul Jules Tillaux (1834–1904) at Beaujon
Hospital [13, 14]. He was head of the surgical clinic at La Pitié and Tillaux of the
Paris Faculty of Medicine in 1885 and 1886, respectively, and appointed hospital
surgeon and assistant to Peyrot in 1892 [13]. Guinard was director of the surgical
department at the Ivery, Bicêtre in 1900, Dubois Municipal House of Health, Paris
in 1901, Tenon in 1903, Saint-Louis Hospital in 1904, and the Hôtel-Dieu, Paris in
1906 [13, 14].
He was president of the Union of Doctors, Seine, vice-president of the Anatomical
Society in 1896; secretary general of the French Society of Surgery and editorial
secretary of Bulletin général de thérapeutique (General Bulletin of Therapeutics);
and secretary and rst-class medical ofcer of the Territorial Army [13]. He was
anointed knight of the Legion of Honor in 1907 and received a prize for his research
on surgical diseases of the abdomen from the French Academy of Medicine in 1911
[13, 14].
In a presentation of a paper titled “De la laparotomie dans les contusions de
l’abdomen” (Laparotomy for abdominal contusions), presented at the French
Surgical Congress in October 1896, Guinard reported two symptoms diagnostic for
intestinal perforation:
[t]wo symptoms, which are essential from the point of view of the diagnosis of perforation.
It is rst the prehepatic tympanic tone and, secondly, a contracture of the abdominal mus-
cles that prevents deep manual exploration. Unfortunately, apart from these two signs, it is
often impossible to conrm the diagnosis [15, p. 874].
11 Abdominal Wall Signs