Emil Perman

Emil Samuel Perman (1856–1946) was a Swedish surgeon specialising in abdominal surgery and orthopaedics.

Perman was an early Swedish advocate of operative treatment for appendicitis and gastric ulcer disease. His surgical interests also included gastroenterostomy, abdominal adhesions, incarcerated diaphragmatic hernia, childhood hernia and gastroptosis.

He is eponymously associated with the Perman sign of appendicitis, first described in 1904 as pain in the ileocaecal region elicited by pressure on the left side of the abdomen. The sign later became closely associated, and frequently conflated, with the Rovsing sign described by Niels Thorkild Rovsing in 1907.

Biographical timeline

• Born on June 6, 1856 in Östersund, Sweden, the son of Erik Emil Constantin Perman and Märta Maria Burman.
• 1876 – Commenced medical studies at Uppsala University.
• 1882 – Medicine candidate at Uppsala University.
• 1887 – Completed his medical licentiate.
• 1889 – Awarded his doctorate in medicine at Uppsala University.
• 1891–1896 – Docent in surgery at the Karolinska Institutet.
• 1892–1899 – Chief physician at the Kronprinsessan Lovisas vårdanstalt för sjuka barn (Crown Princess Lovisa’s Hospital for Sick Children), Stockholm.
• 1899–1916 – Chief physician of the surgical department at Sabbatsberg Hospital, Stockholm.
• Died on February 5, 1946, aged 89, at Lovö, Sweden. Buried at Norra begravningsplatsen, Stockholm, on February 21.

Medical Eponyms

Perman sign (1904)

Clinical sign associated with appendicitis in which pressure on the left side of the abdomen produces pain localised to the right iliac fossa or ileocaecal region.

1904 – Perman published Om indikationerna för operation vid appendicit samt redogörelse for å Sabbatsbergs sjukhus opererade fall [On the indications for operation in appendicitis and an account of cases operated upon at Sabbatsberg Hospital]. He reviewed 244 patients operated on for appendicitis at Sabbatsberg Hospital between 1899 and 1904 and discussed the clinical findings used to determine the need for early operation.

Within his discussion of findings suggesting significant pathological change in and around the appendix, Perman described:

Perman provided a clinical example. Case 154 concerned a 25-year-old man with acute right-sided abdominal pain. On examination there was tenderness in the right iliac fossa, which was also elicited by pressure on the left side. Operation the following day revealed abundant seropurulent fluid and an appendix with a small perforation at its tip.

Perman’s original description was simply of pressure on the left abdomen producing pain localised to the ileocaecal region. He did not specify a particular direction of pressure or propose a mechanism for the phenomenon.

1907 – Niels Thorkild Rovsing published Indirektes Hervorrufen des typischen Schmerzes an McBurney’s Punkt. Ein Beitrag zur Diagnostik der Appendicitis und Typhlitis. His specific described a specific manoeuvre was intended to indirectly reproduce pain at McBurney’s point. The left hand was placed flat over the descending colon in the left iliac fossa. The right hand pressed the fingers of the left hand into the colon, which was compressed while the hand was moved upwards towards the left colonic flexure.

I press with my right hand onto the fingers of the left hand that is lying flat against the colon descendens [descending colon] and then let the hand glide up toward the splenic flexure…The entire method is based upon isolated rise of pressure within the colon.

Rovsing 1907

1911 – Perman published Uber die Bedeutung des indirekten Druckschmerzes bei Appendizitis. He reproduced his 1904 description and stated that he had recognised and used the phenomenon before Rovsing’s publication.

Perman explained that he had discovered the sign while beginning abdominal palpation away from the suspected inflammatory focus. In patients with appendicitis and periappendicitis, pressure on the left abdomen could produce pain at McBurney’s point without pain beneath the examining hand. He attributed this to pressure, displacement, stretching or jarring transmitted towards the inflamed region rather than Rovsing’s proposed movement of colonic contents and caecal distension.

Perman also reported that attempts to reproduce pain using Rovsing’s specific colonic-compression manoeuvre when ordinary left-sided pressure was negative had been unsuccessful. Nevertheless, he acknowledged Rovsing’s role in drawing wider attention to the diagnostic phenomenon.

The simpler sign described by Perman subsequently became widely conflated with, and commonly referred to as, Rovsing sign.

Key medical contributions

Perman specialised in abdominal surgery and orthopaedics and was an early advocate of operative treatment of appendicitis and gastric ulcer disease. He was also an early pioneer of gastroenterostomy in Sweden.

His publications addressed appendicitis and its surgical treatment, gastroenterostomy, abdominal adhesions, incarcerated diaphragmatic hernia, hernia in children and gastroptosis.

Major Publications

• Perman ES. Om indikationerna för operation vid appendicit samt redogörelse for å Sabbatsbergs sjukhus opererade fall [About the indications for surgery in appendicitis and an account of cases at Sabbatsberg Hospital]. Hygiea 1904; 66(2): 797-847 [Perman sign]
• Perman ES. Leber die Angiotripsie in der allgemeinen operativen Chirurgie. Nordisk Medicin, 1904
• Perman ES. Uber die Bedeutung des indirekten Druckschmerzes bei Appendizitis. Zentralblatt für Chirurgie. 1911; 38(2): 1593-1596

References

Biography

• Personal communication – Bengt Perman
• Allmaenna Svenska Laekartidningen. 1904: 620

Eponymous term

• Sundberg H. Salpingitis purulenta som komplikation till graviditet. Hygiea 1917; 79(2): 1178-1194
• Index-catalogue of the Library of the Surgeon-General’s Office, United States Army. Series III, Volume I. 1918: 537 and 676
• Wallerström C. Om diagnosen av den akuta appendiciten, särskilt med hänsyn till det s k Rovsings symtom. Svenska läkartidningen. 1931; 28: 1385-98.
• Räf L. Skandinaviska kirurger först med beskrivning av tecken pâ appendicit. [The men behind the syndrome: Emil Perman and Nils Thorkild Rovsing. Scandinavian surgeons were the first to describe signs of appendicitis] Läkartidningen 1984; 81(32-33): 2829-30
• Ráf L. Appendicit ett hett ämne från det första till det hundrade året. Läkartidningen 2004; 101(6): 454-455
• Cadogan M. Appendicitis eponymous signs. LITFL

David Yu

David Yu, M.D., Ph.D. Full time anesthesiologist in the department of Perioperative medicine and Intensive Care (PMI), Karolinska University Hospital, Sweden. Dual board certified in internal medicine, and anesthesiology and critical care. Clinical interests are the critically ill patient, hemodynamic cases, perioperative echocardiography and procedural awareness, and of course all things ECG! | Squiggler |

Mike Cadogan

BA MA (Oxon) MBChB (Edin) FACEM FFSEM. Emergency physician, Sir Charles Gairdner Hospital. Passion for rugby, medical history, medical education, and asynchronous learning #FOAMed evangelist. Editor-in-Chief and Webmaster of Life in the Fast lane, LITFL | On Call 4e| Eponyms | Books | Horology |