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Thus, Guinard, Demons, and Hartmann reported rigidity of the abdominal wall in
intestinal perforation (involuntary guarding) caused by intra-abdominal injury.
Guinard also identied the prehepatic tympanitic percussion sound found in intesti-
nal perforation.
11.2.5 Demons Sign
Jean Octave Albert Demons (1842–1920) was born in Saint-Ciers-de-Canesse,
France, and received his medical degree from Bordeaux University in 1868 [16, 17].
He spent his entire medical career at the Faculty of Medicine, Bordeaux, being
appointed surgeon to the hospitals of Bordeaux in 1869 and was responsible for
directing the surgical department of the Children’s Hospital, followed by Saint-
André Hospital [17]. Demons was appointed assistant professor in 1871, associate
professor in 1879, chair of the surgical clinic, and professor and chair of the surgical
clinic from 1886 to 1911 [16–18]. He was a surgeon during the Franco-Prussian
War in 1870 and served on the Girondine Ambulance Francis de Luze [18].
Demons founded the Tastet Girard Hospital and contributed to the foundation of
the Protestant Nursing Home in Bordeaux [16, 19]. He was editor of the Archives
Provinciales de Chirurgie (Provincial Archives of Surgery); was a national corre-
spondent for the division of surgical pathology of the French Academy of Medicine
from 1892 to 1920; and founded, chaired, and presided over a session of the French
Congress of Surgeons in 1891 [16–20]. He received the Knight’s Cross in 1873 and
was an ofcer in the Legion of Honor in 1894 [17, 18].
In his presentation on abdominal wall trauma and the involvement of visceral
organs, he reported at the French Surgical Congress in October 1897 that:
A more frequently encountered and decisive symptom is abdominal wall rigidity. The
marked rigidity of the wall is sometimes accompanied by moderate distension or, in some
cases, by attening or even excavation of the abdomen. This physical nding suggests vis-
ceral involvement and properly accompanies ruptures of the hollow viscera [21, p. 976; 22,
p. 385].
Thus, Guinard, Demons, and Hartmann reported that rigidity of the abdominal wall
(involuntary guarding) is a sign of intra-abdominal injury and intestinal perforation
(Table11.1).
11.2.6 Hartmann Sign
Henri Albert Charles Antoine Hartmann (1860–1952) was born in Paris, France,
studied medicine at the Sorbonne, Paris, was an interne at Hôtel-Dieu from 1881 to
1882, demonstrator of anatomy in 1884, and prosecutor of anatomy at the Faculty
of Medicine, Paris, in 1886 [23].
11.2 Eponymous Signs
362
He received his medical degree in 1887 and the Argenteuil Prize for his thesis
titled “Des cystitis douleureuses” (Painful cystitis) from the Faculty of Medicine,
Paris [23–25]. Hartmann was chief of the urology clinic at the Lariboisière Hospital
in 1892, appointed agrégé of surgery in 1895, taught at the surgical clinics at Pitié
Salpêtrière Hospital, was deputy director of operative surgery at Lariboisière
Hospital in 1898, professor and chair of clinical surgery at Bichat Hospital in 1909,
and professor of surgery at Hôtel-Dieu. He was head of the rst surgical clinical
chair at Hôtel-Dieu from 1914 to 1930 [23–28].
Hartmann was editor of the Journal Gynécologie et Obstétrique (Gynecology
and Obstetrics) and co-founder of Ligue nationale contre le cancer (French National
Cancer League) [23, 28]. He was vice-president of the Anatomical Society in 1892
and the French Association of Surgery in 1922 [25]. He was a founding member of
the French Association of Urology and the Society of Obstetrics, Gynecology, and
Pediatrics [25]. Hartmann was elected member of the Academy of Medicine in
1918, served as its president in 1936, and was the Grand Ofcer of the Legion of
Honor in 1946 [23–26]. Among his many appointments, he was president of the
French Society of Surgery and was president of the French Surgery Congress in
1919, to name a few [23]. Hartmann was elected to the French Academy of Sciences
in 1945 and received an honorary degree of a fellowship from the Royal College of
Physicians, England, in 1913 [23]. His name is best recognized eponymously for his
description of the procedure involving oversewing the rectal or distal colonic stump
after resectioning the colonic segment (Hartmann procedure and pouch) [25].
As to a description of his character by Moulonguet:
His curiosity for exact and precise facts and humility before them were most striking. We
have often spoken of his complex character, but we still need to sufciently note the con-
trast between his aggressiveness towards men and his docility towards things and events.
Through examples, it is easy to show how his practice and teaching have always obediently
followed the lesson of facts without bias and pride [26, p. 169]. (…) No less remarkable
were his qualities as an observer. It has often been recalled how he interviewed a patient,
interrupting the explanations and comments to hear the story of the raw fact, the statement
of the pure symptom [26, p. 170]. (…) Docility in the face of facts, admirable gift of obser-
vation, solid erudition, meticulous awareness during the operation, these qualities can be
given as examples. They justify what his pupil, Lecène, said of him: “It was with Hartmann
that I understood what surgery should be, elevated to the height of true science and carried
out with respect for others.” [26, p. 170].
In a report by Hartmann, he stated (Table11.1):
In October 1898, I told you that in the presence of a contusion of the abdomen, I considered,
in the absence of any other symptom, the existence of contracture of the wall, not limited to
the contused point, as a clear indication for an immediate celiotomy. In the absence of con-
tracture, whatever the reason, I abstain from any intervention [29, p. 234–235].
Thus, Guinard, Demons, and Hartmann reported that abdominal wall rigidity (invol-
untary guarding) is a sign of intestinal perforation from an intra- abdominal injury.
11 Abdominal Wall Signs
363
11.2.7 Sergent Sign
Émile-Eugène-Joseph Sergent (1867–1943) was born in Paris, France, and served
as an extern of the Hôpitaux de Paris (Hospitals of Paris) from 1890 to 1891, intern
in 1892, and a hospital physician in 1903 [30, 31]. He became head doctor at the
Charité Hospital in 1911 and rose to the rank of professor and chair of propaedeu-
tics in 1921 [30]. During World War I, Sergent was a medical lieutenant colonel
head of the tuberculosis service, Le Vésinet, France, and during World War II, he
served as chief at Boucicaut Hospital. He was chair at Broussais Hospital in 1933
and an honorary doctor in 1937 [30].
Among his accolades, he was honorary doctor of the Faculties of Quebec and
Montreal, an honorary professor of the faculties of Bucharest and Montevideo, and
an honorary member of the Academy of Medicine, Buenos Aires [30]. He was
awarded Grand Ofcer of the Legion of Honor for his outstanding service in 1943.
For his work on adrenal insufciency, he received the Saintour Prize for his research
on syphilis and tuberculosis. Among his other awards, he was Grand Ofcer of the
Crown of Romania and Yugoslavia, to name a few [30].
He was elected member of the National Academy of Medicine, the section of
medical pathology in 1919, and served as its president in 1941; president of the
Medical Society of Paris Hospital and the Society of the Study of Tuberculosis in
1924; and member of the Supervisory Board for Public Assistance [30, 32].
Sergent described what he believed to be a pathognomonic nding in patients
with acute adrenal insufciency (Table11.1):
This pathognomonic sign, which I previously discussed, would remove any doubt about the
diagnosis. I encountered this diagnostic nding in a previous case to which I have already
alluded in connection with acute adrenal insufciency. I have described this symptom as the
adrenal white line phenomenon. When a line is traced with the ngernail on the patient’s
skin, this line grows pale and outlined, by its whiteness, the path followed by the nger [33,
p. 383].
Sergent postulated that the “white line” was caused by reex capillary spasm. This
sign has been inconsistently described in the literature as taking place on the chest
or abdomen [34, 35]. However, Sergent did not specify in his publication the region
of the body where the skin is scratched.
11.2.8 Beevor Sign
Charles Edward Beevor (1854–1908) was born in London, England, and received
his medical degree from the University College Hospital London in 1881 [36, 37].
He was elected master of the Royal College of Physicians in 1882 and fellow in
1888 [36, 38, 39]. He served as a house physician at the University College Hospital
and resident medical ofcer at the National Hospital for the Paralyzed and Epileptic
at Queens Square, Bloomsbury, London [36]. This was followed by an appointment
11.2 Eponymous Signs
364
as an assistant physician at National Hospital for the Paralyzed and Epileptic in
1883 and 1885 as an assistant physician at the Great Northern Central Hospital [38].
He rose to the rank of physician at both hospitals [36–38].
Beevor contributed most extensively to the eld of neurology, with his most clas-
sic works including Diseases of the Nervous System: A Handbook for Students and
Practitioners in 1898, Muscular Movements and Their Representation in the Central
Nervous System published in 1904, The Diagnosis and Localisation of Cerebral
Tumours published in 1907, and The Distribution of the Different Arteries Supplying
the Human Brain published in 1908 [40, 41]. The last work was signicant because
it provided precise blood supply localization to various brain regions. His areas of
interest, expertise, and crowing achievements were the diagnosing and localization
of cerebral tumors and arterial supply to the brain [42, 43].
He was elected president of the Neurological Section of the Royal Society of
Medicine from 1907 to 1908, ofcer and trustee of the Medical Society of London,
and honorary secretary to the Association for the Advancement of Medicine by
Research [36].
A description of his character as articulated by Sir Victor Horsely, who rst
worked with him as a clinical clerk, “His extraordinary good nature, his never-
failing graceful courtesy, and his untiring efforts to help us made an ineffaceable
impression and inaugurated an unbroken friendship of exactly thirty years.” [36,
p. 1785].
Another friend and colleague wrote:
Beevor’s character was singularly winning and attractive. Sweet, simple, guileless, unself-
ish, retiring, and affectionate; none who knew him as I did could help loving him. No breath
of slander ever passed his lips. His mind and thoughts were white and clean as those of a
child. He never uttered an unkind word. It is most difcult to convey in words an adequate
idea of the simplicity and beauty of Beevor’s life [39, p. 1855].
In his talk delivered before the Royal College of Physicians of London in June 1903,
Beevor reported a method to access the abdominal wall muscles (Table11.1):
I observed some years back a symptom which enables the investigator to tell if there is any
weakness of the upper or lower part of the recti. The symptom is the movement of the
umbilicus. In health, in the movement of sitting up, the umbilicus does not alter its position,
but if from a lesion of the lower part of the spinal cord or its nerves, the part of the recti
below the umbilicus be paralyzed, the normal upper part of the recti will draw up the umbi-
licus, sometimes to the extent of an inch. As the abdominal wall at the level of the umbilicus
is supplied by the tenth dorsal root, any marked elevation of the umbilicus in the act of sit-
ting up would show a lesion between the tenth and twelfth dorsal segments of the cord or
the roots coming off from them. In the case where I rst observed this symptom there was
a malignant growth involving the cord at the level of the eleventh and twelfth dorsal roots.
In two cases, one a myopathy and the other a case under the care of my colleague, Dr.
Ormand, I have seen the umbilicus drawn downwards, due, I have no doubts, to weakness
of the part of the recti situated above the umbilicus [44, p. 40].
Thus, Beevor sign refers to the superior movement of the umbilicus when the lower
portion of the rectus abdominal muscle is paralyzed.
11 Abdominal Wall Signs
365
11.2.9 Ransohoff Sign
Joseph Ransohoff (1853–1921) is the senior of the three generations of Ransohoff
physicians. His son was Dr. Joseph Louis Ransohoff (1880–1958), and his grandson
was Dr. Joseph Ransohoff (1915–2001) [45]. Joseph Ransohoff (1853–1921) was
born in Cincinnati, Ohio, and received his medical degree from the Medical College
of Ohio in 1874. He continued his medical studies in Paris, Vienna, Würzburg,
Berlin, and London and, on his return, was appointed demonstrator of anatomy in
the Medical College of Ohio in 1877 [46–48].
Ransohoff was a professor of anatomy from 1879 to 1891 and anatomy and clini-
cal surgery from 1891 to 1902. When the Medical College of Ohio merged with the
University of Cincinnati in 1896 to acquire the new name, the Medical Department
of the University of Cincinnati Ransohoff held an appointment of Principles of
Surgery from 1902 to 1905, followed by professor of surgery in 1905 [46–49]. He
was also on staff as a surgeon at the Cincinnati General Hospital, Good Samaritan,
and dean of the Jewish Hospitals in Cincinnati [46, 47].
He was awarded fellow of the Royal College of Surgeons, London, in 1877, a
fellow of the American College of Surgeons, and a member of several societies and
associations, including the American Medical Association and American Academy
of Medicine [47, 49].
As to a glimpse of his character:
Not only was he a leading physician and surgeon, but he was a public-spired citizen, and he
shared a deep and keen interest in his native city, its people, and its institutions. He was
exceedingly popular among the members of his profession, and he was especially kind and
helpful to the young physicians. He loved his profession and sought no place or preferment
outside its limits [49, p. 226].
Ransohoff described a 53-year-old man with a ruptured common bile duct and bile
peritonitis (Table11.1):
On inspection of the abdomen, attention was called to a marked jaundice of the umbilicus.
The navel was of a distinct saffron-yellow color in strong contrast with the rest of the skin
over the abdomen. It was the only evidence of jaundice [50, p. 396]. (…) I wish here to call
attention to a sign which was referred to in the case of the ruptured duct before the incision
was made, and one to which I believe attention has never before been directed. It is the
localized jaundice of the umbilicus. Although a single case is not usually sufcient to war-
rant the assumption that something new has been observed, this feature was so marked that
I cannot refrain from believing that further observation will give to this localized jaundice
some value as a sign of free bile in the peritoneal cavity. In the case presented, this feature
gained in interest as the staining of the subperitoneal fat with bile was observed in the inci-
sion through the abdominal wall. The jaundice is probably the result of inhibition. It makes
itself manifest rst in the integument of the navel, because this part is thinner than the rest
of the abdominal wall. It is possible, of course, that by reason of the anatomic relations of
the round ligament of the liver to the transverse ssure that is a retrograde ow of bile
through the lymphatics toward the navel, just the caput medusa is produced by cirrhosis [50,
p. 397].
Thus, Ransohoff sign refers to the saffron-yellow discoloration of the umbilicus in
rupture of the common bile duct.
11.2 Eponymous Signs
366
11.2.10 Livierato Sign
Panagino Elenco Livierato (1860–1936) was born in Kefalonia, Greece, and
received his medical degree in 1886 [51, 52]. He was appointed ordinary professor
of special medical pathology in Genoa, Italy, in 1890 and served at the medical
clinic in Palermo, Italy, in 1895 [51, 52].
Livierato observed in a 35-year-old man postprandial chest heaviness and occa-
sional shortness of breath that resolved with activity and was absent with walking
up the stair or a hill. An increased pulse rate and right cardiac border extending to
the midline of the sternum were found on physical examination. He described a
palpatory technique as a means for detecting the early development of right ven-
tricular failure prior to the onset of symptoms. This involved tapping the abdominal
wall by placing (Table11.1):
[t]he patient in a supine position and delineate the area of absolute obtuseness of the heart.
As seen, it has limits: internally, the median line of the sternum; externally, the vertical
papilla where the apex beat is perceived; superiorly, the upper border of the fourth left rib
on the left margin of the sternum, which curves gradually downwards reaching the region
of the cardiac apex; inferiorly, the sixth rib. The pulse has a regular rate and rhythm. Tap
repeatedly on the midline of the abdomen, beginning in the epigastrium to the umbilicus
along the path of the abdominal aorta. We will determine which cardiac area is modied and
can be dened. By delineating the area of the dullness of the heart again, it is seen that its
limit has extended considerably to the right. The inner limit reaches the margin to the right
of the sternum, while the upper and the exterior are slightly modied. The cardiac dullness
extends to the right for about three centimeters. The pulse is increased somewhat in fre-
quency, and the pulmonary component of the second sound is accentuated. I now asked the
patient to rise from the bed and walk quickly around the room several times and again
delineated the area of cardiac dullness. As is seen, we nd this area considerably narrowed.
The internal limit reaches the margin to the left of the sternum, the upper area is slightly
lowered, almost unchanged, and the left remains the same. The pulse is stronger and more
frequent than previously. Moreover, from the subjective point of view, following this move-
ment, the individual, as they see, does not experience any problems with either breathing or
palpitations [53, p. 5].
He accounted for the proposed pathogenesis, which he named the abdomino-
cardiac reex:
In our case, we have seen in a schematic way that the irritation of the abdominal nerves has
given rise to the expansion of the right ventricle in an obvious and conspicuous way [53, p.
6]. (…) Usually, a person experiences no subjective feeling because the right ventricle
makes up for the increase in energy. However, as soon as the myocardium, due to any cause,
is compromised in its potentiality, the impediments that cause reduced pulmonary blood
ow explain the dilation of the right ventricle. Thus, we understand why not all individuals
were suffering from stomach, liver, or other diseases present with dilation of the heart under
the mentioned conditions. The tonicity and energy of the myocardial ber must decrease for
dilatation to occur. In our case, by tapping on the abdomen, we produced excitement due to
the sympathetic, which causes a constriction of the pulmonary vessels. We have detected a
strengthening of the tones of the lung and the dilation of the dullness of the heart to the
right. Our simple observation proves that we did not excite the vagus because the pulse not
11 Abdominal Wall Signs
367
only does not slow down but increases in frequency [53, p. 7] (…). The ingested foods
produce excitement, starting from the stomach’s mucosa, causing the constriction of pul-
monary vessels due to the sympathetic. The semiological artice used by us, which we call
the abdominal-cardiac reex, enables us to explain our patient’s bothersome sensation and
cure him judiciously. This simple artice shows that the myocardium of this individual has
little energy and tone [53, p. 7].
Thus, Livierato sign refers to the dilation of the right ventricle when tapping the
abdominal wall in the midline from the epigastrium to the umbilicus. The phenom-
enon was believed to be caused by vasoconstriction due to activation of the abdomi-
nal sympathetic nerves.
11.2.11 Cruveilhier–Baumgarten Sign
11.2.11.1 Jean Cruveilhier
Jean Cruveilhier (1791–1874) was born near Limoges, France, studied medicine
at the University of Paris, and received his medical degree in 1816 based on the
thesis Essai sur l’anatomie pathologique en général (Essay on Pathological
Anatomy in General) [54, 55]. He was appointed professor of anatomy at the
medical school of Montpellier, France, in 1825 and later chair of pathological
anatomy at the Faculty of Medicine, Paris, from 1835 to 1865 [54–59]. He also
served as physician-in-chief and director of the Maternity, Salpêtrière, and Charité
Hospitals [54, 57, 58].
Cruveilhier was a member of the French Academy of Medicine of the pathologi-
cal anatomy section in 1836 and served as president in 1859. He was elected com-
mander of the Legion of Honor in 1863 and an honorary fellow of the Royal
Medical-Surgical Society in 1862 [54, 56–58].
His passion in medicine throughout his career was pathological anatomy culmi-
nating in his most signicant work titled Anatomie Pathologique du Corps Humain
(rst volume published in 1829 and second volume in 1842), which consisted of
plates of macroscopic illustration of morbid anatomy [58]. Given his contribution to
pathological anatomy, Rudolf Ludwig Carl Virchow (1821–1902) recognized him
as “the father and patriarch of pathological anatomy” [59, 60].
As to a description of his character as a eulogy by his friend and pupil M.Bardinet,
who was at that time headmaster of the medical school in Limoges:
Cruveilhier was distinguished not only by a superior intellect but also by the noblest quali-
ties of the heart. All men admired his unswerving rectitude, his genuine simplicity, his
equanimity of temper, which remained unrufed by the breath of calumny. He was enthusi-
astically devoted to his patients and science. His industry was unagging, and he scarcely
allowed himself the indispensable repose. (…) Rarely has a man of science been so thor-
oughly kind and considerate to his patients; rarely have the latter more warmly reciprocated
a welcome so sympathizing [57, p. 570].
11.2 Eponymous Signs
368
11.2.11.2 Paul Clemens von Baumgarten
Paul Clemens von Baumgarten (1848–1928) was born in Dresden, Germany, stud-
ied medicine at the Universities of Königsberg and Leipzig, and received his medi-
cal degree from the latter in 1873 [61, 62]. He served as an assistant anatomist at the
Anatomical Institute of the University of Leipzig from 1873 to 1874, an associate
professor of pathological anatomy at the University of Königsberg from 1877 to
1881, and a professor from 1881 to 1880 [61, 63]. He was appointed chair of patho-
logical anatomy and general pathology at the University of Tübingen in 1889 [61,
63]. He was a commander second class of the Royal Saxon Order of Albrecht and
recipient of the Cross of Honor of the Order of the Württemberg Crown in 1895 [63].
Baumgarten described the case of a 16-year-old man with anemia, splenomegaly
ascites, liver cirrhosis, and complete patency of the umbilical vein. He proposed
three states of the umbilical vein in liver cirrhosis: i. persistent patency, ii. partial
patency, or iii. Complete obliteration (Fig.11.1):
If the intra-abdominal part of the umbilical vein remains patent, it abnormally communi-
cates directly at the umbilicus with the epigastric veins. It then extends from the umbilicus,
just as in the embryonic state, along the posterior edge of the falciform ligament to the
hepatic porta and in a slight curve to the portal venous sinus similar to that occurring in the
embryo [64, p. 104]. (…) After this outline of the three modes of vascular connection
between the portal vein and the system of deep veins of the anterior abdominal wall, let us
look at our case. There can be no doubt that mode 1, a total openness of the intra-abdominal
part of the umbilical vein acts [64, p. 105]. (…) The reason for the total openness to be
regarded as proven hereafter can be seen in the abnormal direct connection which exists
between the umbilical vein and the deep inferior epigastric veins close to the umbilicus.
This allows blood to ow through the umbilical vein postpartum along its entire intra–
abdominal course, thereby preventing its obliteration along the entire route [64, p. 106].
He compared his case to Cruveilhier’s description published in Anatomie
Pathologique du Corps Humain (Pathological Anatomy of the Human Body)
(Table11.1):
In Cruveilhier’s case, the persistence of the umbilical vein throughout its length from the
umbilicus to the portal sinus is, as he rightly says, “a fact beyond dispute”; because the
umbilical vein is located on the inferior edge of the falciform ligament, it communicates
directly with the umbilicus and vastly expanded epigastric veins (caput medusae). There is
no evidence for the obliteration of the umbilical vein trunk. In none of the later observa-
tions, apart from ours, has proof of total patency of the umbilical vein been furnished with
the same certainty as Cruveilhier. Our case coincides with that of Cruveilhier. Anyone who
compares the relevant illustration in Cruveilhier’s well-known atlas of pathological anat-
omy with the illustration of our preparation attached to this treatise will readily admit the
essential agreement. Decisive for understanding the large vessel in the inferior edge of the
suspensory ligament as an umbilical vein that has remained open is, as already mentioned,
the absence of a cord corresponding to the obliterated umbilical vein next to the large open
vessel, which has been demonstrated in our case as well as in Cruveilhier’s case. The only
minor difference is that in Cruveilhier’s case, the supercial epigastric veins, not the deep
ones, as in ours, ow directly into the umbilical vein. It is fascinating that in Cruveilhier’s
case, too, atrophy of the liver was associated with the umbilical vein remaining patent,
although this was only smooth atrophy, not granular atrophy [64, p. 107].
Thus, Cruveilhier-Baumgarten sign refers to the multiple dilated umbilical and
paraumbilical veins on the abdominal wall (caput medusa) in patients with portal
hypertension.
11 Abdominal Wall Signs
369
Fig. 11.1 Cruveilhier–Baumgarten sign (by Ryan Yale)
11.2.12 Hofstätter Sign
Robert Wilhelm Ludwig Hofstätter (1883–1970) was born in Vienna, Austria, and
received his medical degree from the University of Vienna in 1907. He was the
father of Peter Robert Adolf Maria Hofstätter (1913–1994), a social psychologist
[65, 66]. He pursued training in gynecology at the second medical university clinic
and university women’s clinic in Vienna from 1908 to 1910 [65, 66].
Hofstätter was assistant to Heinrich von Peham (1871–1930) at the Vienna
General Polyclinic in 1913. He habilitated at the University of Vienna in obstetrics
and gynecology in 1919 and was appointed associate professor in 1939 [65]. He was
a provisional manager in the Department of Gynecology at the Vienna General
Polyclinic, head of the outpatient clinic for gynecological diseases at the Vienna
General Hospital from 1936 to 1938, and the women’s department of the children’s
hospital from 1938 to 1940 [65]. He served as a senior physician during World War
II and as a German nationalist and Nazi eugenicist [67–69]. After the war, he was in
private practice in obstetrics and gynecology and was appointed professor of obstet-
rics and gynecology at the University of Vienna in 1951. He was a member of the
Austrian Cancer Society in 1958 and the German Society of Obstetrics and
Gynecology in 1962 [65, 66].
Since eponyms are honoric terms, Hofstätter sign should not be used in medical
discourse because of his views and afliations during National Socialism.
Hofstätter reported the case of a 36-year-old female who developed a “blood
discoloration of the skin above the umbilical hernia,” later believed to be caused by
a ruptured ectopic pregnancy [70, p. 524]. Hofstätter found on the physical exami-
nation (Table11.1):
11.2 Eponymous Signs
370
The skin above it and a small area around it are suffusion with blood and, in some places,
have already turned yellowish. The tumor is moderately rm, has large lobes, and is slightly
diffusely sensitive to pressure. There is an empty sound above it; not reducible as a whole
and does not change size after coughing or straining [70, p. 524].
Thus, Hofstätter sign refers to a palpable ecchymotic and yellowish discoloration
involving the umbilical and periumbilical regions in cases of ectopic pregnancy.
Thomas Stephen Cullen (1868–1953) described a similar nding 2years later (see
Cullen sign).
11.2.13 Wynter Sign
Walter Essex Wynter (1860–1945) was born in Brompton, London, England, and
received his medical training at the Middlesex and Bartholomew Hospitals, London,
qualifying as a member of the Royal College of Surgeons in 1883. He was elected
fellow of the Royal College of Surgeons in 1885, medical baccalaureate, London in
1887, and a medical degree in 1888 [71, 72]. Wynter served on staff at Brompton
Hospital, the Hospital for Sick Children, and Middlesex Hospital [71]. At the
Middlesex Hospital, he was appointed assistant physician in 1891, physician and
lecturer in medicine in 1901, and senior physician and consulting physician in 1925
[72]. He was elected fellow of the Royal College of Physicians in 1897. During his
retirement in Newbury, he was a consultant at Newbury District Hospital, a town
council member, and chairman of the public health committee [71, 72].
As to a description of his character by Taylor:
Wynter will long be remembered by his contemporaries and pupils for his unvarying kind-
ness and charm; he had a most lovable nature and could not have had an enemy in the world
[71, p. 101].
Among his contributions to medicine, he described a sign of acute brinous pericar-
ditis secondary to rheumatic heart disease with polyarthritis and, in 1891, a method
using a Southey’s tube with rubber drainage at the L2 intervertebral space for per-
forming a lumbar puncture. This nding was published vemonths after Heinrich
Irenaeus Quincke (1844–1922) reported a lumbar puncture using a ne needle can-
nula between the third and fourth lumbar vertebral spaces at the tenth Medical
Congress at Wiesbaden in 1891 [73, 74]. According to Wynter, “The rst case which
the method was tried was February 1889” [74]. This suggests that the attribution to
the person who rst performed the rst lumbar puncture should be attributed
to Wynter.
Wynter described a nding he observed in two cases of pericarditis (Table11.1):
The sign suggested in this communication is inhibition of the action of the diaphragm,
indicated by suppression of normal abdominal respiratory movement, and has probably
been hitherto overlooked through examination being unduly restricted to the chest in such
cases [75, p. 40]. (…) There is no doubt, however, that when attention is directed to the
matter, and a denite note made as to the presence or absence of abdominal movement, this
feature will be found fairly constant in acute pericarditis, especially that with brinous
11 Abdominal Wall Signs