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Published online before print August 27, 2004, 10.1148/radiol.2331031985
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(Radiology 2004;233:7-12.)
© RSNA, 2004

Historical Perspectives

The Rigler Sign and Leo G. Rigler1

Ann M. Lewicki, MD, MPH

1 From the Department of Radiology, Georgetown University, 2801 New Mexico Ave NW, Washington, DC 20007. Received December 4, 2003; revision requested January 30, 2004; revision received February 13; accepted February 27. Address correspondence to the author (e-mail: aLewicki@juno.com).

Index terms: Radiology and radiologists • Radiology and radiologists, history • Radiology and radiologists, research


   INTRODUCTION
TOP
 INTRODUCTION
THE RIGLER SIGN
 BIOGRAPHIC SKETCH
 THE RIGLER LEGACY
 COMMENT
 REFERENCES
 

Editor’s Note: The interested reader will find additional details regarding Dr Rigler in several of the references cited by Dr Lewicki in this Historical Perspectives. For personal insights about Dr Rigler, please see the publication by Dr Heitzman in this issue of Radiology.

Anthony V. Proto, MD, Editor

Only a few eponyms are used in radiologic practice, unlike in the specialty of neurology or surgery. A recently created Web site of medical eponyms lists some 6495 names; only 11 names are listed in the radiology category (1). The Rigler sign is not included on this short list, but also not included is Hounsfield’s name in any category of this eponym Web site (1). In radiology, there has been a trend in recent years to attach the name of the inventor to a device. One such example is the Guglielmi detachable coil. This coil was developed in 1991 at the Leo G. Rigler Research Center (2). Most radiologists are quite familiar with the Rigler sign, which allows for the detection of pneumoperitoneum on supine radiographs of the abdomen. Yet not everyone may be aware of what we owe Leo Rigler and what he contributed to our specialty.

Eponyms usually recognize a person’s discovery. The double-wall sign of free intraperitoneal air remains an important observation, but it is only one of Dr Rigler’s major contributions to radiology. He is not the only exception to the usual use of eponyms. In a recent collection of neurologic eponyms, we learn that Theodor Schwann, whose name is associated with the Schwann cell, also made other important discoveries that would be more far-reaching in the development of medicine than his description of the histology of nerve cells (3).

That there are so few eponyms in radiology is probably related to a trend that occurred in medicine in general and that lasted for about 50–60 years until some 2 decades ago, as stated by Koehler et al in the preface of their book (4). This trend away from eponyms paralleled other changes in medicine, with the discipline becoming more scientific and less descriptive. Is there then still any value in eponyms? As Kaminski points out, eponyms help remind us that advancement of knowledge still depends on people, and that is important when our lives are so dominated by technology (5).

I will now describe the Rigler sign, present a biographic sketch of Dr Rigler and describe my perception of the Rigler legacy.


   THE RIGLER SIGN
TOP
 INTRODUCTION
 THE RIGLER SIGN
BIOGRAPHIC SKETCH
 THE RIGLER LEGACY
 COMMENT
 REFERENCES
 
In 1941, Rigler described a new sign with which the presence of free air in the peritoneal cavity could be recognized (6). Pneumoperitoneum made it possible to see the wall of gas-containing viscera. The walls of these viscera contrasted with intraluminal gas and gas in the peritoneal cavity. This sign was demonstrated on supine radiographs of the abdomen. He described four such cases in this 1941 report. Today this is known as the Rigler sign, and major textbooks continue to list and describe it (7,8).

In his report, Rigler emphasized that this sign was only observed when large quantities of free gas were present in the abdomen, such as is usually the case with perforation of the colon. He also stressed that it frequently was observed in very ill patients in whom only limited radiographs of the abdomen could be obtained, often with a bedside technique.

Recognizing free air—and perforation—on a supine radiograph could, in many patients, signal that a catastrophic event had occurred when the clinical findings had not changed or could alert one to the need for an intervention (6).

The Rigler sign of pneumoperitoneum can also be applied in computed tomographic (CT) examination of the abdomen. On images from a CT examination, air outside the wall of viscera can be distinguished from fat with a high degree of certainty. Ly illustrated the Rigler sign recently and discussed the differential diagnosis of pneumoperitoneum (9). Ly also described phenomena that can simulate free gas in the peritoneal cavity.


   BIOGRAPHIC SKETCH
TOP
 INTRODUCTION
 THE RIGLER SIGN
 BIOGRAPHIC SKETCH
THE RIGLER LEGACY
 COMMENT
 REFERENCES
 
Leo George Rigler was born October 16, 1896, in Minneapolis, Minnesota. After attending public schools, he continued his education at the University of Minnesota, where he received his BS degree in 1917, a BM degree in 1919, and an MD degree in 1920 (10). This was followed by a 1-year internship in the St Louis City Hospital. Following his internship, he ventured into practice as a general practitioner in New England, North Dakota, which he soon abandoned, returning to the University of Minnesota. There, he then held a 1-year position as a teaching fellow in the department of internal medicine. In 1923–1926 he served as a radiologist at the Minneapolis General Hospital. While holding this position, he also found time to train in radiology at the Battle Creek Sanatorium under the supervision of Dr J. T. Case and at the University of Michigan under Dr P. J. Hickey. He also served for some of the time as an assistant in anatomy at the University of Minnesota and was engaged in the private practice of radiology. In 1924, with funding from Dean Lyon, who was the dean of the University of Minnesota Medical School, Dr Rigler took off for Europe to visit various clinics but primarily to spend the year in Stockholm, Sweden, at the Karolinska Institute with Dr Gosta Forssell (11). He was Dr Forssell’s first American trainee. While there, he also learned to speak Swedish (12).

On his return from Europe he was appointed an associate professor of radiology at the University of Minnesota, a full-time appointment and the first such appointment ever at that University (10). He was then 31 years old. Two years later, he became a full professor and, in 1933 at the age of 37 years, was asked to chair the department of radiology, again the first full-time chairman of radiology at the University of Minnesota. He held that position until 1957.

Dr Rigler was certified by the American Board of Radiology in 1934 while a full professor. He was the 68th candidate to receive this recognition. Since 1934, the American Board of Radiology has certified 54,088 physicians (Hattery RR, written communication, 2004). The American Board of Radiology was incorporated and organized at a meeting in May 1934 (13).

In 1957, Dr Rigler moved to the West Coast. By then, the radiology department at the University of Minnesota had expanded considerably and developed into sections of radiation therapy, neuroradiology, and nuclear medicine. Dr Rigler himself worked in all facets of radiologic diagnosis, yet early on he focused on radiology of the chest and abdomen.

On the West Coast, he first served as the executive director of the Cedars of Lebanon–Mount Sinai Hospitals from 1957–1963. He then returned to academic medicine and became a professor of radiology at the University of California, Los Angeles (UCLA). He was by then 67 years old. At UCLA, he directed the postgraduate program in diagnostic radiology. He held this position until his death in 1979 at age 83. Dr Rigler’s contributions to radiology and medicine, his many awards and honors have been summarized in tributes to him (14–16).


   THE RIGLER LEGACY
TOP
 INTRODUCTION
 THE RIGLER SIGN
 BIOGRAPHIC SKETCH
 THE RIGLER LEGACY
COMMENT
 REFERENCES
 
When asked why he chose to become an academic radiologist, Dr Rigler, looking back on a 50-year career, simply stated, "My wife and I decided that a teaching career, a career in the university, the opportunity to do investigation as well as teach others was what suited our personalities and aspirations best" (17).

Dr Rigler’s interest in radiology was sparked during his internship in St Louis (14). There he saw Dr Leroy Sante, who had just been appointed director of radiology at St Louis General Hospital, use fluoroscopy and apply radiologic techniques as a diagnostic tool (14). Dr Forssell had a profound influence on Rigler’s career and life. Wangensteen writes about this, quoting from a letter that Matyl Rigler, Dr Rigler’s wife, wrote to him (11). Sante and Forssell were pioneer radiologists who used the new roentgen method for the care of patients; they were also formidable scholars (18,19).

Teaching
Very soon after taking over the radiology department at the University of Minnesota, Dr Rigler instituted an interdepartmental radiology conference, a novel concept at the time at the University of Minnesota. It was held each Saturday, and it became very popular; so it spread to other medical school departments (11) (Fig 1). He knew that learning is an experience that must continue throughout life, so he tried to find a way where he could reach the practicing radiologists and physicians in the community. Thus, he developed a postgraduate course in 1936; a course of intense learning for trainees but also for those out in practice who needed such a review and/or an update. Physicians and scientists from other disciplines participated in the teaching. This course was developed long before the concept of continuing medical education credits arrived, and it was entirely devoted to such learning. Again, this venture proved a great success, attracting a large attendance over the years. The Radiology Department of the University of Minnesota held its last postgraduate course in September 2002. The title of this postgraduate course was Strategic Imaging. During that 2002 conference, the Rigler Lecture was delivered and celebrated (20).



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  		Figure 1. A teaching conference with Dr Rigler at far left, undated. (Image courtesy of U.S. National Library of Medicine, Bethesda, Md.)

 
Dr Rigler’s involvement with teaching continued after he left the University of Minnesota. Thus, he participated in a cancer conference held in 1963 at Harvard Medical School in Boston, Massachusetts, while holding the position of executive director at the Cedars of Lebanon Hospital. This interdisciplinary conference was sponsored by the New York Academy of Sciences, the American Cancer Society, and the National Cancer Institute, and a monograph of the proceedings was later published.

In the decades following the second world war, Dr Rigler traveled with the World Health Organization and helped establish and strengthen clinical radiology in India, Iran, Israel, and other countries (10) (Fig 2).



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  		Figure 2. Dr Rigler (arrow), holding a fluoroscope, teaching in India, 1953. (Image courtesy of U.S. National Library of Medicine, Bethesda, Md.)

 
Throughout his career, he never lost interest in teaching to small groups, and he was effective and graceful during these interactions. Medical students and colleagues sought out his advice and benefited from consulting with him (22) (Fig 3).



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  		Figure 3. Dr Rigler teaching, undated. (Image courtesy of U.S. National Library of Medicine, Bethesda, Md.)

 
All along he was concerned with how future radiologists should be trained. Was there too much emphasis on training them to be proficient in performing procedures? How supervised should residents be and when should they be more involved in the decision process? When he was asked to evaluate the residency program at Stanford University in California in 1963, he addressed these and other concerns in a follow-up letter (22). He reflected on how the specialty of radiology had changed over the preceding 50 years during an annual oration in 1970 at the annual meeting of the Radiological Society of North America, and he presented data on how the demands for radiologic services had increased and how the practice of radiologists had become more complex (23).

Scholarship
Dr Rigler started writing and publishing early in his career. His first article was published in 1923 in the Archives of Medicine (24), and he continued to write throughout his life. Dr Rigler was an author of over 200 publications; he wrote, edited, and translated and edited six books. He also wrote prefaces and introductions to several textbooks (10). I will review some of his publications to show that what interested him then is still pertinent and of interest to us now.

Because Dr Rigler was well grounded in anatomy and pathology, he was able to conceptualize and translate what he saw on a radiograph into a three-dimensional image of anatomy and pathology, but he greatly valued the contributions of anatomists (25,26). Today’s radiologists still need such solid grounding in anatomy and pathology more than ever before, because current imaging techniques display anatomy in exquisite detail; on the other hand, they no longer need to guess about spatial relationships.

Dr Rigler early on realized that there were findings on the static radiograph that reflect physiology and pathophysiology (27).

He became concerned that radiography did not always allow detection of disease at the early stage, when an intervention could cure a patient or improve prognosis (28). This led to an exploration of the relationship of pernicious anemia as a risk factor for carcinoma of the stomach. He published, with Kaplan, several landmark articles on this subject (29–31). One is based on 43 021 autopsies with a statistical analysis of the data (30). Dr Rigler was interested in carcinoma of the lung, the radiographic findings of this disease, in particular when it manifests at an early stage (32,33). He wondered whether screening for asymptomatic disease was the answer to this dilemma (33). He realized that there was and would be overutilization of what radiology offers and was concerned how this should be balanced with the benefits from screening, a dilemma we continue to face (34).

The risks of radiation exposure to personnel and patients concerned Dr Rigler (35,36). He anticipated that computers would play a big role in radiology (37). There are other subjects that he wrote about in a scholarly way, some based on information from the laboratory, others on clinical observations.

At UCLA, Dr Rigler was able to help establish a research facility for imaging research. Such a laboratory had for some time been the vision of Dr William Hanafee, who could foresee the great progress that could be made in radiology and medicine in particular through interventional approaches (38) (Fig 4). Dr Hanafee was the chairman of radiology when this laboratory opened. The center was established with private funds and was named The Leo G. Rigler Center for Radiological Sciences (38,39). At the dedication ceremony on April 23, 1971, the keynote speaker was the Assistant Secretary for Health and Scientific Affairs, U.S. Department of Health, Education, and Welfare, Dr Roger Egeberg (39).



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  		Figure 4. Dr Rigler at UCLA, undated. (Image courtesy of U.S. National Library of Medicine, Bethesda, Md.)

 

   COMMENT
TOP
 INTRODUCTION
 THE RIGLER SIGN
 BIOGRAPHIC SKETCH
 THE RIGLER LEGACY
 COMMENT
REFERENCES
 
In this review I have tried to show how Leo Rigler succeeded as a teacher and investigator, how he contributed to the development of the specialty of radiology and how he influenced medicine through radiology. He was able to do so because he was unusually gifted, capable of recognizing the central issue of a specific radiologic problem or a more general one in medicine. A rigorous intellect and intellectual honesty led him to constantly examine his ideas. As new knowledge became available, he did not hesitate to revise his thinking. He was always developing, growing (40). This commitment to medicine and radiology and the tremendous joy he derived from doing his chosen work never left him until he died at age 83. This is what inspired people around him. They wanted to be close to him, they wanted to learn from him. An unusually large number of Dr Rigler’s trainees became outstanding radiologists, leaders of the profession. A partial list of these outstanding Rigler trainees can be found in a letter by Dean Field who was at the time the associate dean emeritus of the UCLA School of Medicine (41). Dr Rigler achieved international stature as a radiologist and scientist, so in later years visitors from outside the United States made it a point to seek him out. They knew they would invariably benefit from his presence (42).

In a recent report, Crewson and Sunshine (43) explored the professional job satisfaction of radiologists and found that it has been declining. Only 51% of radiologists would recommend a career in radiology to a college student, but that has risen from what it had been in 1988, when it stood at 42%. Sunshine et al (44) more recently also evaluated the training and employment experience of residents and fellows. Most trainees were satisfied with the quantity and variety of patients and procedures they had been exposed to during their training, but 11% of residents and 6% of fellows thought that the instruction they had received was not as good as it should have been. The most common reason cited seemed to be a lack of interest in teaching by the faculty (44).

Only a small number of residents chose academic radiology as a career path. Why is that so, when such exciting developments are occurring in biologic research laboratories? It seems that, more than ever, we have difficulty translating what is happening in research to the classroom and to our professional trainees. The Howard Hughes Medical Institute is trying to address this deficiency and has established a program where 20 outstanding teachers who are also scholars have been selected and are generously funded. They are charged with developing teaching programs that will train future academic scientists. Something comparable is needed in radiology, so radiologists can be trained who can use the imaging tools of the profession to explore the most basic biologic processes of health and disease (45).

Next time the Rigler sign of pneumoperitoneum is mentioned in a teaching session, we should take time to think and talk about the legacy that Leo Rigler left for us. So that what he started becomes also part of our life, so that radiology continues to evolve and grow into directions beyond the autopsy to the molecular level and beyond in ways that even Leo Rigler could not foresee.


   ACKNOWLEDGMENTS
 
I am indebted to Elizabeth Fee, PhD, John P. Rees, and Paul Theerman, PhD, of the National Library of Medicine History of Medicine Division for their invaluable help; also to Aaron Hilliard and Deborah B. Hill in the chair’s office, Department of Radiological Sciences, David Geffen School of Medicine at UCLA. My thanks also to the staff of the Dahlgren Memorial Library, Georgetown University, Washington, DC, for their untiring assistance.


   FOOTNOTES
 
Abbreviation: UCLA = University of California, Los Angeles,

Author reported no financial relationship to disclose.

See also the Historical Perspectives by Heitzman in this issue.


   REFERENCES
TOP
 INTRODUCTION
 THE RIGLER SIGN
 BIOGRAPHIC SKETCH
 THE RIGLER LEGACY
 COMMENT
 REFERENCES
 

  1. Enersen OD. Who named it?. Available at: www.whonamedit.com/index/cfm. Accessed October 6, 2003.
  2. Guglielmi G, Vinuela F, Sepetka I, Macellari V. Electrothrombosis of saccular aneurysms via endovascular approach. J Neurosurg 1991; 75:1-7.[Medline]
  3. Karenberg A. The schwann cell. In: Koehler PJ, Bryn GW, Pearce JMS, eds. Neurological eponyms. New York, NY: Oxford University Press, 2000; 44-50.
  4. Koehler PJ, Bryn GW, Pearce JMS, eds. Neurological eponyms New York, NY: Oxford University Press, 2000.
  5. Kaminski HJ. Neurological eponyms (book review). N Engl J Med 2001; 345:380-381.[Free Full Text]
  6. Rigler LG. Spontaneus pneumoperitoneum: a roentgenologic sign found in the supine position. Radiology 1941; 37:604-607.
  7. Field S. The acute abdomen. In: Freeny PC, Stevenson GW, eds. Margulies and Burhenne’s alimentary tract radiology. 5th ed. St Louis, Mo: Mosby–Year Book, 1994; 2020-2075.
  8. Cho KC, Baker S. Manifestations of intraperitoneal air. In: Meyer M, eds. Dynamic radiology of the abdomen. 5th ed. New York, NY: Springer-Verlag, 2000; 307- 331.
  9. Ly JQ. The Rigler sign. Radiology 2003; 228:706-707.[Free Full Text]
  10. Biographical sketch MS C 377. Leo George Rigler papers. Series personal and biographical 1923–1981. file biographical data, modern manuscripts collection, history of medicine division. Located at: U.S. National Library of Medicine, Bethesda, Md.
  11. Wangensteen OH. Tribute to a wonderful colleague, teacher, scientist, and humanist Leo G. Rigler. Minn Med 1980; 63:791-794.
  12. O’Brien WA. Leo G. Rigler, MD—an appreciation (editorial). Radiology 1945; 44:297-298.
  13. Madewell JE, Hattery RR, Thomas SR, et al. American Board of Radiology maintenance of certification. Available at: www.theabr.org/MOC_RefDoc.htm. Accessed August 18, 2003.
  14. Jacobson HG. Leo G. Rigler, MD. Radiology 1980; 135:247-248.
  15. Mellins ZH, Peterson HO. Memorial: Leo G. Rigler, 1896–1979. AJR Am J Roentgenol 1980; 135:421-422.
  16. Jorgens J, Zheutlin N, Steckel R. 1980 University of California: in memoriam—Leo G Rigler, radiological sciences: Los Angeles. University of California History Digital Archives. Available at: dynaweb.oac.cdlib.org:8080/dynaweb/uchist/public/inmemoriam/inmemoriam1980/@Generic _B. Accessed July 20, 2004.
  17. Mellins HZ, Leo G, Rigler MD. interview (videotape). 1973. Atlanta, Ga: National Audiovisual Center, in cooperation with Alpha Omega Alpha. Available at: U.S. National Library of Medicine, History of Medicine Division (Bethesda, Md).
  18. St Louis University School of Medicine Sante lecture. Available at medschool.slu.edu /radiology/index.phtml?page=santelecture&cat=conference. Accessed September 30, 2003.
  19. del Regato JA. Gosta Forssell: our history and heritage. Int J Radiat Oncol Biol Phys 1977; 2:783-790.[Medline]
  20. 65th annual course radiology 2002 strategic imaging. Available at: www.med.umn.edu/cme/brochures2002/radiology/radiologybro2002.html. Accessed February 8, 2004.
  21. Letter from S. Warren, G.T. Pack, and N.H. Moss to Leo G. Rigler, December 20, 1963, MS C 377, Leo George Rigler papers. Series personal and biographical 1923–1981, file correspondence, modern manuscripts collection, history of medicine division. Located at: U.S. National Library of Medicine, Bethesda, Md.
  22. Letter from Leo G. Rigler to H. Abrams, May 27, 1963, MS C 377, Leo George Rigler papers. Series personal and biographical, 1923–1981, file correspondence, modern manuscripts collection, history of medicine division. Located at: U.S. National Library of Medicine, Bethesda, Md.
  23. Rigler LG. Radiology comes of age. Radiology 1970; 95:245-255.[Medline]
  24. Rigler LG, Ulrich HL. Blood sugar reaction following intravenous injection of glucose. Arch Intern Med 1923; 32:343-352.[CrossRef]
  25. Rigler LG. Segmental anatomy of the lung (editorial). Radiology 1949; 52:583-583.[Medline]
  26. Rigler LG. Contributions of anatomists to radiology: as exemplified by the work of Edward Allen Boyden. J Lancet 1962; 82:125-128.[Medline]
  27. Rigler LG. Functional roentgen diagnosis: anatomical image—physiological interpretation: Caldwell lecture. Am J Roentgenol Radium Ther Nucl Med 1959; 82:1-24.[Medline]
  28. Rigler LG. Roentgen examination of the stomach in symptomless persons. JAMA 1948; 137:1501-1507.
  29. Rigler LG, Kaplan HS. Pernicious anemia and tumors of the stomach. J Natl Cancer Inst 1947; 7:327-332.
  30. Kaplan HS, Rigler LG. Pernicious anemia and carcinoma of the stomach: autopsy studies concerning their inter-relationship. Am J Med Sci 1945; 209:339-348.
  31. Kaplan HS, Rigler LG. Pernicious anemia and susceptibility to gastric neoplasms. J Lab Clin Med 1947; 32:644-653.
  32. Rigler LG. The roentgen signs of carcinoma of the lung. Am J Roentgenol Radium Ther Nucl Med 1955; 74:415-428.[Medline]
  33. Rigler LG. The earliest roentgenographic signs of carcinoma of the lung. JAMA 1966; 195:655-657.[CrossRef][Medline]
  34. Rigler LG. Is this radiograph really necessary? Radiology 1976; 120:449-450.[Abstract]
  35. Rigler LG. X ray burns of the physician’s hands (editorial). Minnesota Med 1930; 12:553-554.
  36. Adams FH, Rigler LG. Reduction of radiation to children (editorial). Circulation 1964; 30:161-162.[Free Full Text]
  37. Rigler LG. Computers: some assets and liabilities (editorial). Radiology 1963; 81:327-329.
  38. UCLA Monthly May 1971 (Davidson M. The invisible doctor) MS C 377, Leo George Rigler papers. Series personal and biographical, 1923–1981, file The Leo G. Rigler Center for Radiological Sciences, modern manuscripts collection, history of medicine division. Located at: U.S. National Library of Medicine, Bethesda, Md.
  39. Dedication ceremonies MS C 377, Leo George Rigler papers. Series personal and biographical, 1923–1981, file The Leo G. Rigler Center for Radiological Sciences, modern manuscripts collection, history of medicine division. Located at: U.S. National Library of Medicine, Bethesda, Md.
  40. Presentation by J. Youker on May 27, 1979, MS C 377, Leo George Rigler papers. Series personal and biographical, 1921–1981, file honorary degree, modern manuscripts collection, history of medicine division. Located at: U.S. National Library of Medicine, Bethesda, Md.
  41. Letter from J. Field to the Sheen Award Committee, February 25, 1969. Located at: Chair’s office, Department of Radiology, David Geffen School of Medicine at UCLA, Los Angeles, Calif.
  42. Letter from Olsson O to the Sheen Award Committee, February 20, 1969. Located at: Chair’s Office, Department of Radiology, David Geffen School of Medicine at UCLA, Los Angeles, Calif.
  43. Crewson PE, Sunshine JH. Professional satisfaction of U.S. radiologists during a period of uncertainty. Radiology 1999; 213:589-597.
  44. Sunshine JH, Simon C, Bushee GR, Schepps B. 1997 graduates speak out: initial employment experience of residency and fellowship graduates. AJR Am J Roentgenol 2000; 175:1225-1232.[Abstract/Free Full Text]
  45. Cech TR. Rebalancing teaching and research (editorial). Science 2003; 299:165.[Abstract]



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