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381
Jeans described a nding observed in cases of peritonitis (Table11.1):
In a normal patient the abdomen comes out when the chest comes out (except for the rst
three or four respiratory movements, which should be ignored because all patients breathe
self-consciously when rst exposed). If after the rst few breaths the abdomen goes in when
the chest comes out, then the patient has a diffuse leak, will be found on palpation to have
complete rigidity, and on lapratorum to have general peritonitis. (…) Moreover, there is a
further renement. If a transverse crease half an inch above the umbilicus is seen in an
abdomen which has the reverse movement described above-or no movement at all, then the
patient is likely to have a perforated duodenal or gastric ulcer. If, on the other hand, there is
a transverse motionless axis about 2in. below the umbilicus round which the abdomen
“rocks” i.e., the wall goes in below this axis and out above it—then the trouble is probably
in the appendix, which is leaking mainly into the pelvis and less so towards the upper abdo-
men [117, p. 729].
Thus, Jeans sign refers to either the absence of abdominal wall movement or the
abdominal wall moving inward during inspiration (reverse respiratory direction)
above a transverse crease located half an inch above the umbilicus in cases of per-
forated duodenal or gastric ulcer.
11.2.24 Carnett Sign
John Berton Carnett (1876–1934), father of John Berton Carnett Jr. (1914–1963),
was born in Williamsport, Lycoming County, Pennsylvania, USA, and received his
medical degree from the University of Pennsylvania Medical School in 1899 [118,
119]. He was appointed surgical assistant to Edward Martin (1859–1938) at the
University and Philadelphia General Hospitals and Instructor at the University of
Pennsylvania medical school in 1901 [120]. During World War I, he served as chief
of the surgical division of the Red Cross Base Hospital No. 20 at the University of
Pennsylvania Hospital and as a lieutenant colonel in Château Guyon, France [118,
120]. He received a personal letter of commendation from the American Red Cross
and Surgeon General, Washington, D.C., for his exceptionally meritorious and con-
spicuous services [120].
He was appointed professor of surgery at the Graduate School of Medicine of the
University of Pennsylvania, followed by vice-dean of surgery [119]. He became
chief surgeon of the Graduate Hospital and the radiologic services at the Philadelphia
General Hospital [119]. Carnett served as president of the Board of Trustees of the
North American Sanitarium for the Treatment of Surgical Tuberculosis and was a
member of the College of Physicians, and the Philadelphia Academy of Surgeons,
among others [118].
Carnett described a method for differentiated pain arising from the abdominal
wall from an intra-abdominal origin. The maneuver consisted of two stages (A and
B) (Table11.1) (Fig.11.2):
11.2 Eponymous Signs
382
A. In any patient complaining of abdominal pain and tenderness, the examiner follows
the classic advice of gaining the condence of both the patient and his muscle and
then palpates in the usual manner. Irrespective of whether the tenderness is parietal
or intra- abdominal the examiner’s ngers as a rule, will dip fairly deep into the abdo-
men before tenderness is elicited. The deep position of the ngers has generally been
regarded as proof that the tenderness is intra-abdominal, but in a surprisingly high
percentage of cases this assumption will prove to be an error as shown by the
next step.
B. The examiner keep his ngers at the most sensitive area he has discovered on deep
pressure and requests the patient to make his abdominal muscles rigid by contracting
his diaphragm or by raising and holding his head from the pillow; as the patient tenses
his muscles, the examiner relaxes his nger pressure so that his ngers rise out of the
abdomen; and then with the patient’s abdominal muscle tense the examiner reapplies
pressure with his nger tips and he also may exert a little twisting motion with them
[121, p. 625].
If the origin of the abdominal pain is intra-abdominal, then only the A test will be
positive. If the skin and muscles of the abdominal wall are involved, then both A
and the B test will be positive. If the parietal peritoneum is involved, the patient
will frequently report the pain is less during B than A test. However, if the perito-
neal inammatory process or a local abscess involves the muscles of the anterior
abdominal wall both the A and B portions of the tests will be positive. A false nega-
tive test may occur in multiparous women who are unable to tense their abdominal
muscles.
A positive Carnett sign is when both the A and B test are positive signifying that
the pathology involves the cutaneous and subcutaneous tissue and muscles of the
abdominal wall. Variation on the how to perform the maneuver has been described
by different authors. Suleiman and Johnston (2001) require that the supine patient
tense the abdominal wall by lifting the head and shoulders off the examining table
[122]. Bailey in contrast stated that the patient is asked to extend both legs and raise
the feet from the bed [123].
A positive Carnett sign most commonly occurs in diseases involving the abdomi-
nal wall and includes abdominal hernia, entrapment neuropathies (rectus nerve, tho-
racic lateral cutaneous nerve, ilioinguinal and iliohypogastric nerve), endometriosis,
diabetic radiculopathy, and hematoma (abdominal wall and rectus sheath).
Carnett sign has been shown to be useful bedside diagnostic technique for con-
rming abdominal wall involvement [124, 125]. In a study of 120 patients present-
ing to the emergency room with abdominal pain, Thomson and Francis (1977)
found that of 23 of 24 (96%) with a positive Carnett sign, only one had an abnormal
laparotomy [124].
11 Abdominal Wall Signs
383
Fig. 11.2 Carnett sign (by Ryan Yale)
11.2 Eponymous Signs
384
11.2.25 Fothergill Sign
William Edward Fothergill (1865–1926) was born in Southampton, England, and
received his Bachelor of Medicine with distinction (rst-class honors and gold
medal) from the University of Edinburgh in 1893 [125–129]. He was appointed
house physician and clinical assistant to Sir Alexander Russell Simpson (1835–1916),
professor of obstetrics in the gynecology wards at the Royal Inrmary, and from
1893 to 1895in the Royal Maternity Hospital, Edinburgh [126–128]. He received
his medical degree in 1897 with a gold medal distinction [127, 130].
In Manchester, he was assistant lecturer to Sir William Japp Sinclair (1846–1912),
professor of obstetrics, followed by an appointment as an assistant surgeon at
Northern Hospital for Women and Children in 1899 [126]. At the Royal Inrmary,
he was instrumental in establishing the rst clinical laboratory serving as its director
in 1899 [126]. He was appointed as staff to the Southern Hospital in 1904 (Southern
Hospital later became incorporated with St. Mary’s Hospital). He was named an
ordinary fellow of the Edinburgh Obstetrical Society in 1906, an assistant in 1907,
and a full surgeon in 1919 at the Manchester Royal Inrmary [128, 131].
At the University of Manchester, he was a lecturer in obstetrics and gynecology
in 1901, rose to the ranks of professor of systematic obstetrics and gynecology in
1920, and was later appointed professor of clinical obstetrics and gynecology in
1925 [126]. He also held appointments as a senior surgeon for Women at St. Mary’s
Hospital and consulting gynecological surgeon at Manchester Royal Inrmary [126].
He wrote the Manual of Midwifery (1896), Lectures to Midwives and Maternity
Nurses (1907), Golden Rules in Obstetric Practice (1910), and Manual of Diseases
of Women (1910), the latter containing a revised classication of diseases aficting
women [127, 132]. He perfected and wrote extensively on the operation for pelvic
oor repair originally devised by Archibald Donald (1860–1937), colloquially
referred to as the Manchester operation [127].
As described by Fairbairn:
He was a man we could ill spare, for he had rare force or character and the power of making
his inuence felt, and it is no exaggeration to say that there is not another of his day and
generation who did more to mold gynecological opinion in this country [127, p. 102].
Fothergill described a bedside maneuver for distinguishing a rectus sheath hema-
toma from an intra-abdominal process (Table11.1):
The most interesting thing about these cases is the diagnosis. The patient complains of pain
and the medical man nds the swelling. The trouble is that he seldom knows how long the
swelling has been present; for patients frequently have masses of various kinds in the pelvis
or abdomen whose presence is not suspected until they complain of pain and submit to
examination. The main point is the recognition that these swellings are part and parcel of
the abdominal wall. This is generally made by noting that they can still be felt when the
recti are in action, and that they become xed as the muscles contract. Another point is that,
when a mass in the abdominal wall is not too large, a resonant note may be obtained through
it by deep percussion [133, p. 942].
Fothergill sign thus refers to the presence of an abdominal wall mass that is palpable
when the abdominal wall is relaxed and tensed, and is xed in position when the
muscle contracts. Additionally, the mass is resonant on percussion. Furthermore, he
11 Abdominal Wall Signs
385
noted that an intra-abdominal mass adherent to the abdominal wall causes similar
ndings to those within the abdominal wall.
11.2.26 Co Tui-Meyer Sign
Frank Wang Co Tui (Xu Zhaodui) (1897–1984) was born in Fujian province, China,
and received his medical degree from the University of the Philippines [134]. He
completed an internship in Chicago from 1923 to 1925 and served as an associate
professor of experimental surgery at the surgical laboratories in the Department of
Surgery at NewYork University and Bellevue Hospital Medical College. He earned
a professorship at the NY University College of Medicine [134].
He was a member of the American Association of the Advancement of Science
American Pharmaceutical Society, chairman of the American Bureau of Medical
Aid to China, and a fellow of the NY Academy of Medicine and NY Academy of
Science [134].
11.2.26.1 Jacob Meyer
Jacob Meyer (1894–1955) received his medical degree from Rush Medical College
in 1916 [135, 136]. He completed his internship at Cook County Hospital from
1916 to 1918 and was appointed instructor in medicine at Loyola University in 1920
[136]. Throughout his career, he maintained several appointments in Chicago,
Illinois, including as associate professor of medicine at the University of Illinois
College of Medicine, attending physician at Cook County Hospital, associate
attending physician at Mt. Sinai Hospital, and senior attending physician at Michael
Reese Hospital. He was a member of the internal medicine and pathology and the
department of gastrointestinal research and medical chief of the “Stomach Study
Group” of the Michael Reese Hospital [136].
Co Tui and Meyer described a nding best observed from either the head or foot of
the bed in patients with perforated peptic ulcer disease and acute appendicitis (Table11.1):
It is a prolonged displacement of the linea alba and the umbilicus to the affected side with
the skin surface disturbance in the form of folds and creases on the side to which the linea
alba and the navel are drawn [137, p. 1779]. (…) The umbilicus is located in the median
raphe made by the decussation of the fascial beres of the rectus sheaths. The sheath in
addition to enclosing the rectus muscles, are reinforced by tendinous slips from such pow-
erful muscles as the obliquus externus, the obliquus internus and transverus abdominis.
This raphe, the linea alba, is represented on the surface by a pigmented line in the nonhairy
abdomen and by the parting of the hairs in the hairy abdomen. (…) A difference in the ten-
sion of the two sides of the abdomen would tend to draw the linea alba, and with it the
umbilicus, toward the side of greater rigidity. The skin surface changes are due to an effort
of the skin to accommodate itself to the contracted underlying surface [137, p. 1779].
Furthermore, they found that the site of greatest rigidity corresponded to the side
where the umbilicus was displaced (pointing toward the side of the disease). They
believed the sign might be falsely negative in obese patients and those who are
either multiparous or have a pendulous abdomen [137].
11.2 Eponymous Signs
386
11.2.27 Mortola Sign
We were unable to identify historical information on G.A. Mortola from Buenos
Aires, Argentina. Mortola described a method for determining intra-abdominal
inammation.
The technique is simple but certain details must be studied carefully in order to avoid errors
of interpretation. The patient is placed in dorsal decubitus with the abdominal muscle
relaxed. The physician takes between the thumbs and index ngers of both hands a large
fold of the anterior abdominal wall at the lower right and left quadrants to determine the
possible existence of cutaneous hyperesthesia and then exercises traction on the cutaneous
folds The same procedure is repeated farther up, and this might be called “aspirating” the
anterior wall of the abdomen [138].
If the parietal peritoneum is inamed, the patient complains of pain when the skin
fold is pulled upward. Mortola found this sign useful in acute or subacute forms of
appendicitis or tuberculous peritonitis without ascites. This nding represents a
somatosensory nerve reex.
11.2.28 Raw Sign
Stanley Collingwood Raw (1910–1994) was born in Spratton, Northamptonshire,
England, and received his medical baccalaureate (MB) and bachelor of science (BS)
from Durham University, England, in 1934 [139, 140]. He received postgraduate
training as a house physician, house surgeon, and resident surgical ofcer at the
Royal Victoria Inrmary, Newcastle-upon-Tyne [139, 140].
He was a member of the Royal Army Medical Corps (RAMC) in 1942 and sub-
sequently a lieutenant colonel in 1945. After World War II, he was appointed con-
sultant at Farnham and Frimley Park Hospitals in 1948 [139, 140].
Raw described a nding for distinguishing diaphragmatic pleurisy from perfo-
rated peptic ulcer disease:
In perforation the onset is nearly always dramatic with little vomiting or change in pulse
and temperature. The pain does not vary, and the patient usually lies still. Breathing is short
and thoracic in type. In pleurisy, rigidity may sometimes be overcome by holding the
breath; in colic, it is commonly removed by breathing; but in perforation it never disappears
completely [141, p. 12].
Thus, Raw sign refers to abdominal wall rigidity that does not completely disappear
with breath holding in cases of peritonitis.
11.2.29 Holman Sign
Emile Frederic Holman (1890–1977) was born in Moberly, Missouri, USA, and
received his medical degree from Johns Hopkins School of Medicine in 1918 [142,
143]. He was appointed research fellow at the Hunterian Laboratory for Experimental
11 Abdominal Wall Signs
387
Surgery, instructor in surgery at Johns Hopkins University Medical School, and
resident surgeon at John Hopkins Hospital. He was a resident surgeon at Peter Bent
Brigham Hospital, Boston, from 1922 to 1923 and an assistant professor of surgery
at Western Reserve Medical School in 1924 [144].
He served as associate professor of surgery in 1925 and chairman of the
Department of Surgery in 1926, a position he held until 1955. He was accepted for
Stanford’s surgical residency and research during his tenure. He conducted sentinel
work in vascular surgery, contributing to understanding an arteriovenous stula
physiology and concepts related to allograft skin grafting rejection [142].
Holman was appointed to the American Board of Thoracic Surgery from 1948 to
1952 [145], elected president of the Society for Vascular Surgery in 1949 and the
American Association for Thoracic Surgery from 1953 to 1954, and honorary mem-
ber of the American Osler Society in 1970 [142, 143, 146, 147]. He was the editor
of the Journal of Thoracic and Cardiovascular Surgery from 1957 to 1962 [148].
He was awarded the Samuel D.Gross Prize from the Philadelphia Academy of
Surgery in 1930 for his work on arteriovenous stulas and the Rudolph Mattas
Medal in vascular surgery, Tulane, in 1954. The Emile F.Holman Chair in Surgery
was established in his honor at Stanford University [143].
As a description of his character:
As a teacher Emile is dynamic, specic and at times a little dramatic if it will emphasize a
point. His knowledge of the scientic literature seems to be boundless. He is always avail-
able, never too busy to consult and confer with associates or assistants, and he is a slave for
work. Meticulous and exacting in his technics, he is never more critical or demanding of
others than he is of himself, and he has been a leading example of humanitarianism in his
clinical work [149, p. 1089–1090].
Holman emphasized the use of abdominal percussion as a method for diagnosing
and determining the location and extent of peritoneal inammation. He recom-
mends that the patient be asked to cough, followed by gently palpation (Table11.1):
The follows light percussion—also begun in presumably unaffected areas—by working
downward from epigastrium in lower abdominal discomfort, toward the epigastrium in
upper abdominal pain, and from the side of the comfort to the side of pain in unilateral
involvement. The area of tenderness is quickly and easily ascertained, its exact extent is
determined and, when deemed important, is outlined on the skin by pencil. All degrees of
intensity of tenderness are encountered, shading gradually from the mild tenderness at the
periphery to the exquisitely painful percussion at the center of the involved areas. The site
of greatest tenderness is usually found over the inammation of longest duration, and this
obviously corresponds with the site where the inammation rst began. This may be of real
diagnostic importance [150, p. 775].
Thus, Holman sign identies an area of tenderness by light percussion.
11.2.30 Fox Sign
John Adrian Fox (1933–2018) was born in Manchester, UK, and received his medi-
cal baccalaureate degree from the University of London in 1957. Fox practiced
general surgery at the Royal Free Hospital, London, in 1957. He was a member,
11.2 Eponymous Signs
388
followed by a fellow in the Royal College of Physicians in 1962 [151]. He was a
consultant surgeon at the Royal Northern Hospital, Clementine Churchill Hospital,
and Edgeware General Hospital in Middlesex in 1972 and an honorary consultant
surgeon at St. Andrew’s Hospital, Doll Hill, London [151, 152].
Fox described in two patients (acute pancreatitis and ruptured abdominal aortic
aneurysm) during the latter course of their disease a bluish discoloration located in
the upper outer aspect of the thigh(s). He reported on the distinct anatomical, patho-
logical, and physiological mechanisms accounting for this process (Table11.1):
Careful examination of the bruised area shows a well-marked upper limit. The straight line
runs parellel to and below the inguinal ligament. It corresponds to the attachment of the
membranous layer of the supercial fascia (Scarpa’s fascia) to the fascial lata of the thigh.
(…) It therefore seems likely that the clinical sign seen in the above two case is produced
by the tracking of the uid extraperitoneally along the fascia of the psoas and iliacus
beneath the inguinal ligament until it becomes subcutaneous in the upper thigh. Scarpa’s
fascia prevents the free forward diffusion immediately below the ligament but below its
attachment the bruising is more rapidly developed [153, p. 194].
Thus, Fox sign refers to ecchymosis over the inguinal ligament in cases of retroperi-
toneal hemorrhage.
11.2.31 Tixier Sign
Léon-Eugène-Joseph Tixier (1877–1976) was an extern from 1900 to 1902 and
intern from 1902 to 1907 at Hospitals of Paris and received his medical degree from
the Faculty of Medicine, Paris, in 1907, followed by an assistant at the pediatric
clinic at the Faculty of Medicine from 1907 to 1919 [154, 155].
During World War I, he served as an aide-major in the bacteriology laboratory of
the First Army and chief surgeon in the IV.Medical District from 1918 to 1919. He
was appointed head of the children’s laboratory in the medical clinic of the Faculty
of Medicine, Paris, from 1919 to 1920 and a physician at the Charité Hospital in
Paris. Tixier was head of the laboratory at the Faculty of Medicine, Paris, in
1939 [155].
We were unable to identify Tixier’s original publication on traumatic abdominal
shock. As described by Keleman:
Particularly in shock, when the patient is prostrate at an early stage from rapid exsanguina-
tion and his abdominal wall offers poor defense. Tixier sign may point to considerable
intra-abdominal hematoma [34, p. 92]. (…) [i]f there is no muscular defense, but a free uid
accumulation in the abdominal cavity, 3–4 impressions, “shakes” performed in quick suc-
cession over the left fossa result in palpable and visible undulation in the right fossa (only
in cases of greater volume uid accumulation) [34, p. 59].
Thus, Tixier sign refers to the absence of abdominal guarding in cases of shock in
cases of intra-abdominal hemorrhage or hematoma.
11 Abdominal Wall Signs
389
Table 11.1 Abdominal wall signs
Name Year Description of sign Signicance
Auenbrugger [7] 1761 Epigastric abdominal swelling Pericardial effusion
Rosenbach [9] 1876 Stroking the abdomen with the ngernail produces a reex retraction. These indentations
are made 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. In
patients with cerebral hemiplegia, no abdominal reex occurs on the paralyzed side. In
contrast, the same occurs promptly and is unchanged on the other side. If hemiplegia is
subacute, the contraction occurs weakly. Even in chronic cases, differences are observed
on both sides of the body
Supercial abdominal
reex
Simon [11] 1895 The chest and abdomen in the epigastric region are exposed. Dyssynchronous chest and
abdominal wall movements occur during respiration during the rst days of meningitis.
Additionally, hyperesthesia of the skin causes brief involuntary reex movements of the
chest and stomach
Supercial abdominal
reex
Guinard [15] 1896
1 Prehepatic tympanic sound
2 Contracture of the abdominal muscles prevents deep manual exploration
Intestinal perforation
Demons [21, 22] 1897 Abdominal wall rigidity is sometimes accompanied by either moderate distension,
attening, or concavity of the abdomen
Intestinal perforation
Hartmann [29] 1901 In abdominal contusion, contracture of the abdominal wall is not limited to the contused
area in the absence of any other symptoms is a clear indication for an immediate
laparotomy
Intestinal perforation
Sergent [33] 1904 A line is traced with the ngernail on the patient’s skin. This line grows pale and is
outlined, by a whiteness, along the nger’s path
Adrenal insufciency
Beevor [44] 1904 In healthy persons, while sitting up, the position of the umbilicus remains unchanged. If
there is a lesion in the lower part of the spinal cord or involves its nerves, the part of the
recti below the umbilicus is paralyzed. The normal upper part of the recti draws the
umbilicus up, sometimes almost an inch
Supercial abdominal
reex
Ransohoff [50] 1906 The umbilicus is of a distinct saffron-yellow color Ruptured common bile
duct and bile peritonitis
(continued)
11.2 Eponymous Signs
390
Table 11.1 (continued)
Name Year Description of sign Signicance
Livierato [53] 1906 The patient is supine on the bed, and the border of the heart is determined through
percussion. Internally, it involves the median line of the sternum; externally, the vertical
papilla of the apex; superiorly, the upper border of the fourth left rib on the left margin of
the sternum curving gradually downwards toward the cardiac apex; and inferiorly at the
sixth rib. The pulse has a regular rate and rhythm. Repeatedly tap on the midline of the
abdomen, beginning in the epigastrium and extending to the navel. 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
exterior are slightly modied. The cardiac dullness extends to the right for about three
centimeters. The pulse is increased, and the pulmonary component of the second sound is
accentuated. Ask the patient to rise from the bed, walk quickly around the room several
times, and again delineate 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 movement, the patient experiences neither problems with breathing
nor palpitation
Right heart failure
Cruveilhier–
Baumgarten [64]
1908 The umbilical vein persists and extends from the portal sinus to the umbilicus, with the
largest one located in the inferior edge of the falciform ligament. Here it communicates
directly to the umbilicus with the vastly expanded supercial or deep epigastric veins
(caput medusae)
Caput medusa
Hofstätter [70]
a
1909 The skin above and a small area around the umbilicus contain suffusion with blood and, in
some places, turns yellow
Ectopic pregnancy
Wynter [75] 1911 Exudative pericarditis
The absence of the normal abdominal wall respiratory movement of the chest causes an
inspiratory recession between the chest and abdomen
Appendicitis with peritonitis
Absence of abdominal wall respiratory movement and no denite evidence of an
inspiratory movement in the chest. However, slight movement in the abdomen’s upper
part is limited in its lower part
Exudative pericarditis,
appendicitis with
peritonitis
11 Abdominal Wall Signs