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8.2.2 Pitts Sign
Bernard Pitts (1848–1914) was born in Sowerby, Yorkshire, England, studied medi-
cine under the tutelage of Joseph Lister (1827–1912) in Edinburgh; and at Scotland
and Cambridge in 1873, and was a clinical clerk and dresser at St. Thomas’s Hospital
in 1873 [9]. He earned his Bachelor of Medicine and Master of Art degrees from
Cambridge in 1875 and served as a resident clinical assistant at Bethlehem Hospital
that same year [10].
Pitts was a house surgeon at St. Thomas’s Hospital in 1876 and under the Red
Cross Society as a surgeon during the Serbo-Turkish War (1876–1877) that same
year [9]. Upon his return to St. Thomas’s Hospital after the war, he was appointed
resident accoucheur, demonstrator of anatomy in 1877, resident assistant surgeon in
1878, resident assistant surgeon in 1878, and extra assistant surgeon in 1882 [9]. At
the Hospital for Sick Children, Great Ormond Street, he was an assistant surgeon in
1882, a surgeon in 1892, and consulting surgeon in 1912 [9, 10].
He was a lecturer on practical surgery at St. Thomas’s Hospital and examiner in
surgery for Cambridge, the Durham Society of Apothecaries, and the Royal College
of Surgeons from 1899 to 1909. Within the Royal College, he was a Hunterian pro-
fessor of surgery in 1983 [9]. Pitts was also a member of the Council of the Nurses’
Cooperation, serving as an advocate for the welfare of nurses [10].
As to a description of his character:
He was one of those all too rare men who hate anything in the way of pretense or sharp
practice, and did not hesitate to speak his mind freely and without fear when occasion
seemed to demand plain speaking. (…) Those who knew him will retain an affectionate
remembrance of his strong character and his unselsh devotion to the interest of others [10,
p.123].
Pitts and Sir Charles Alfred Ballance (1856–1936) reported on three cases of splenic
rupture where:
The diagnosis in these cases was arrived at from the locality of the injury, from the evidence
of internal hemorrhage, from the great increase in the xed dullness in the splenic region,
and from the fact, though both anks were dull on percussion, the right ank alone became
entirely resonant on change of position [11, p.95–96].
Thus, Pitts sign refers to the presence of percussion dullness in the splenic region in
patients with splenic rupture (Table8.1). Pitts name is assigned separately to this
sign, presumably because he was the primary author of the publication.
8.2.3 Ballance Sign
Sir Charles Alfred Ballance (1856–1936) was born in London, UK, studied medi-
cine at St. Thomas’s Hospital, and received his Bachelor of Medicine degree from
London University in 1881 with rst-class honor and gold medal. He was elected
fellow of the Royal College of Surgeons (FRCS) in 1882 [12].
8.2 Splenic Eponyms
280
He was appointed assistant aural surgeon at St. Thomas’s Hospital in 1888, fol-
lowed by an assistant surgeon at the West London Hospital [13]. Ballance was
appointed on staff to the National Hospital for Paralysed and Epileptic Queen
Square, London, from 1891 to 1908 and returned to St. Thomas’s Hospital as a chief
surgeon in 1900 and consulting surgeon in 1919 [12–16]. He was chief surgeon to
the Metropolitan Police from 1912 to 1926 [12, 13, 16]. During World War I, he was
consulting surgeon with the rank of colonel stationed in Malta [12, 13, 15].
Ballance was president of the Medical Society of London in 1906 and the Society
of British Neurological Surgeons in 1927 [13–15]. In the Royal College of Surgeons,
he was an examiner in anatomy from 1887 to 1891, a member of the Court of
Examiners from 1900 to 1919, and elected vice-president in 1920 [14, 15].
Among his many accolades, he was the recipient of the Knight Commander of
the Order of St. Michael and St. George (KCMG) in 1918 and Knight of Grace and
Order of St. John of Jerusalem for his consulting work during the War [12, 15]. He
was also the recipient of honorary degrees from the Universities of Glasgow and
Malta and elected as an honorary fellow of the NewYork Academy of Medicine
[12, 13, 16, 17].
As to a description of his character:
His sincerity and enthusiasm gained him many admirers and friends among his colleagues
at home and abroad. (…) He had a genial personality and a ne presence, and even at an
advanced age his enthusiasms for and sincerity in his work were undiminished. He had an
impelling drive to search for truth, and this and his accomplishments ensure him of a niche
in the Hall of Fame [13, p.148–149].
Ballance described the features of splenic rupture based on the following (Tab le8.1):
i) The locality of the injury, ii) the evidence of internal hemorrhage, and iii) the large xed
dullness in the left ank. The xed dullness in the left loin and splenic region is not present
in intra-abdominal hemorrhage from other organs, and is caused by this region being occu-
pied by large quantities of clot. The dullness, therefore, cannot change with position, and is
pathognomonic of this injury [18, p.357].
Thus, Ballance sign refers to xed dullness in the left loin and splenic region in
patients with splenic rupture. This is the same sign reported by Pitts and Ballance
twoyears earlier.
8.2.4 Pagniello Sign
There is limited historical information on Rafael Pagniello. At the time of the pub-
lication of his sign in 1920, he was a state railway physician in Mel, Italy [19].
Pagniello identied a characteristic nding in patients with malaria (Tab le8.1):
If with the tip of the index or middle nger of the right hand, moderate pressure is applied
at the ninth left intercostal space between the midline and posterior axillary line. The patient
reports a painful sensation located at this point. The pain is associated with a reex muscu-
lar contraction of the trunk or face or verbal communication that the patient is experiencing
pain. (…) Pain may rarely occur when pressure is applied at the eighth, ninth, or tenth
8 Spleen Signs
281
intercostal space. (…) It is best to cautiously apply this maneuver in patients who are sensi-
tive to pain. In this case, the entire palm is applied to the splenic region, starting with the
ngertips at the twelfth rib and gradually moving proximally to the location where the
patient reports that pain is greatest. If continuous pressure is applied to this region, the pain
eventually resolves [19, p.830].
Thus, Pagniello sign refers to palpatory tenderness at the ninth intercostal space
between the clavicular and posterior axillary lines in patients with malaria.
8.2.5 Castronuovo Sign
Giovanni Castronuovo (1873–1944) was born in Sant’Arcangelo, Italy, began his
medical studies in 1889, and received his medical degree from the University of Naples
[20]. He was an assistant to De Renzi at the First Medical Clinic and Institute of
Hygiene and Pathological Anatomy. He was a lecturer in special medical demonstra-
tive pathology in 1903. He qualied by ministerial decree, free lecturing in the Royal
University of Naples medical clinic and was an assistant at the rst clinic and Ospedale
degli Incurabili (Hospital of the Incurables) [20, 21]. He served as head of the free
external polyclinic at the rst clinic and was chief physician at Ospedali Riuniti (United
Hospitals) [20]. At the time of the publication of his sign in 1927, he was head of hos-
pitals and director of the L.Armanni Anatomo-Pathological Institute in charge of the
clinic and atology of exotic and tropical diseases at the Royal University of Naples
[22]. Castronuovo was a member of the Royal Medical- Surgical Academy of Naples
and president of the Order of Doctors in the Province of Naples [20].
Castronuovo described the case of a 21-year-old male with a smooth, non-xed
enlarged spleen measuring >14cm at the seventh left rib at the posterior axilla over
Traube area. The most striking features were (Table8.1):
[t]he plastic modeling, as if it were made of wax or clay so an imprint of the pressing ngers
sink into it and persists without being painful. I believe that this characteristic nding of plas-
tic modeling or malleability of the splenic tissue is caused by anatomical changes that are
important to recognize for differential and pathogenetic diagnostic reasons [22, p.554].
Castronuovo postulated that this phenomenon was caused by splenic hyperemia and
accentuated by gastrointestinal bleeding resulting in specic brous changes to the
spleen. These alterations included hyperplastic changes involving the splenic folli-
cles and pulp that increased cortical thickening, consistency, and increased plastic-
ity of the spleen.
8.2.6 Sailer Sign
Joseph Sailer (1867–1928) was born in Philadelphia, Pennsylvania, and received
his medical degree from the University of Pennsylvania in 1891 [23]. He interned
at Presbyterian and Philadelphia General Hospitals and pursued additional training
in neurology and pathology in Zurich, Paris, and Vienna [23]. Sailer served as a
8.2 Splenic Eponyms
282
demonstrator of morbid anatomy in the Department of Pathology at the University
of Pennsylvania [23]. He transitioned to pursue a career in clinical medicine, where
he was appointed instructor, followed by an associate, assistant, and professor at
the Philadelphia General Hospital in 1912 [23, 24]. He was appointed professor of
clinical medicine at the University of Pennsylvania Medical School and chair of
the Department of Gastroenterology at the Philadelphia Polyclinic [23, 24].
Sailer was involved in forming the Philadelphia Heart Association and
Pennsylvania State Heart Association and was co-founder of the American Heart
Association in 1924, the latter of which he was a member of the executive commit-
tee [24, 25]. He was also a member of the American Gastro-Enterological
Association beginning in 1907 and was elected president of this organization in
1920 and chief promoter of the Philadelphia Children’s Heart Hospital [23, 26].
As to a description of his character Joseph Riesman, a friend and col-
league, writes:
As a teacher Sailer commanded the respect of the students in an unusual degree. His thor-
ough knowledge of medical literature and his vast experience made his lectures important
events in the life of the students of the University of Pennsylvania. (…) In Joseph Sailer the
American Gastro-Enterological Association has lost more than a mere member, it has lost
an inuence for progress and an inspiration to higher ideals. His name will live in our annals
and in the annals of American medicine [23, p.578].
Sailer reported the case of a 27-year-old man with aortic insufciency as well as his
review of three other cases and stated (Table8.1):
If one can draw conclusions from four cases described in detail, the conditions necessary to
cause the pulsation of the spleen are a severe type of aortic insufciency and an infectious pro-
cess. (…) Pulsation, of the spleen, owing to its rarity, can be of no great importance, and even
if it were more common, would probably prove to be nor more than an additional sign of aortic
insufciency, for it is doubtful whether or not it can occur in any other condition [27, p.452].
It is to be noted that Carl Adolph Christian Jacob Gerhardt (1833–1902) previously
described splenic pulsation in patients with rheumatic fever and aortic insufciency
in his 1882 publication titled “Pulsierender Milztumor” [28, 29]:
[a] surprising phenomenon was the marked pulsation in which the hard mass swelled with
each heart systole, expanding on all sides, and shrinking again during systole. One heard a
dull double tone above the mass only at the upper edge of the heard sound. (…) The pulsa-
tion of the swollen spleen was so clear in this case that it could be demonstrated to numer-
ous observers. As one could grasp the spleen tip with the ngers it was easy to prove that it
was not a displacement of the spleen by the movement of the apex, but a true systolic swell-
ing of the organ [29, p.449].
Thus, Sailer and Gerhardt signs refer to the presence of splenic pulsation in patients
with aortic insufciency.
8.2.7 Saegesser Sign
Max Saegesser (1902–1975) was born in Langenthal, Switzerland, studied medi-
cine in Geneva, Zurich, Bern, Munich, Paris, and Basel, and received his medical
degree from the latter in 1927 [30, 31]. He habilitated in surgery in Bern from 1935
8 Spleen Signs
283
to 1937 and was chief physician at the Frutigen District Hospital in 1937, followed
by an appointment at the Viktoriaspital, Bern [30, 31]. He was an associate profes-
sor in 1947 and a full professor at the University of Bern in 1973 [30].
He published the book Spezielle chirurgische Therapie für Studierende und
Ärzte (Special Surgical Therapy for Students and Doctors) beginning in 1946
through 11 editions with translations in Spanish and Italian [32]. Saegesser described
a nding in patients with splenic rupture and those with subcapsular hematoma
(Table8.1):
It has been shown that all of our patients with splenic injuries have pronounced left-sided
phrenic nerve pressure pain. We owe this fact to the observation that a person with a splenic
injury reported severe shoulder pain interpreted as phrenic nerve pain. Subsequently, atten-
tion to every splenic injury and phrenic nerve tenderness was routinely found. The examina-
tion is performed by applying pressure with the thumb of the right hand posteriorly on the
left side of the neck between the sternocleidomastoid and anterior scalene muscles and
directed towards the larynx and spine. As a control, the phrenic nerve pressure pain on the
right side is tested with the same hand movement. The presence of shoulder pain and clearly
detectable pressure pain on the left side provides compelling evidence for splenic injury
[33, p.2179–2180].
Saegesser proposed a pathogenesis for this nding:
The anatomical basis of this hyperesthesia of the phrenic nerve in injuries to the spleen is
that the phrenic nerve leads to sensory branches, which run from the splenic capsule via
sympathetic branches and celiac ganglion to the phrenic plexus and phrenic ganglion, from
where the phrenic-abdominal rami also run in the phrenic nerve sensory bers to the area of
origin (IV. cervical nerve with anastomoses from 3, 4, 5 and 6). It is, therefore, a viscero-
sensitive pain reex [33, p.2180].
Thus, Saegesser sign refers to shoulder pain occurring after pressing using the
thumb of the right hand posteriorly on the left neck between the sternocleidomas-
toid and anterior scalene muscles in patients with splenic rupture and subcapsular
hematoma.
8.2.8 Nixon Sign
Robert Kenneth Nixon Jr. (1921–1997) was born in Santa Barbara, California,
USA, and received his medical degree from Northwestern University Medical
School in 1946 [34]. He completed an internship and residency at Cook County
Hospital in Chicago, Illinois, followed by a hematology fellowship at the Hektoen
Institute in Chicago, Illinois, from 1951 to 1952 [34]. He joined Henry Ford Hospital
in 1954 and rose to the rank of head of the second medical division in 1966 and act-
ing chairman of the Department of Medicine from 1984 to 1985 [35].
He was a physician volunteer in the Cabrini Clinic in the inner City of Detroit,
Michigan, beginning in 1955 and chief of medicine on the SS Hope from 1962 to
1972 [34]. He was appointed chairman of the Henry Ford Hospital medical board in
1973 and clinical professor of medicine at the University of North Carolina School
of Medicine in 1986 [34].
8.2 Splenic Eponyms
284
As to a description of his character by R.J.Priest, “Henry Ford Hospital has been
fortunate to have distinguished service from a doctor of such clinical and research
acumen and social responsibility. Dr. Nixon’s career has touched us with pride and
gratefulness” [34, p.292].
Nixon in 1954 described a method for determining spleen size (Table 8.1,
Fig.8.1):
The patient is placed in the right lateral recumbent position with the left arm extended for-
ward and upward sufciently to clear the left lower part of the thorax. In this position the
spleen lies above the stomach and colon, permitting determination of its upper and lower
borders of dullness. After palpation for the lower border on inspiration, percussion is initi-
ated at the lower level of pulmonary resonance in approximately the posterior axillary line
and carried downward obliquely on a general perpendicular line toward the lower midante-
rior costal margin. Normally the upper border of dullness is measured 6 to 8cm above the
costal margin. Dullness increased over 8cm is indicative of splenic enlargement in the adult
[35, p.166].
Thus, Nixon sign refers to the percussion technique for delineating spleen size.
Nixon believed this technique was helpful in patients with a muscular and rigid
abdominal wall with minimal splenic enlargement and those unable to cooperate by
taking a deep breath during palpation.
Fig. 8.1 Nixon sign (by Ryan Yale)
8 Spleen Signs
285
8.2.9 Castell Sign
Donald Overton Castell (1935–2021) was born in Washington, D.C., USA, and
received his medical degree from George Washington School of Medicine in 1960
[36]. He was a medical intern from 1960 to 1961 and a resident from 1962 to 1965
at the National Naval Medical Center, Bethesda, Maryland [36–38].
He was appointed staff internist and consultant in gastroenterology from 1965 to
1967 at the Great Lakes Naval Hospital, Chicago, Illinois. He pursued a gastroen-
terology fellowship at Shattuck Hospital Tufts, followed by additional training at
Boston University, Boston, Massachusetts, from 1968 to 1969 [37]. Castell was
chief and later director of the Philadelphia Naval Hospital’s clinical investigation
service, chief of the gastroenterology division, and director of gastroenterology
research and faculty at Jefferson Medical College, Philadelphia, Pennsylvania
[37, 39].
He was captain and chairman of medicine at the National Naval Medical Center;
professor and vice chairman of medicine at the Uniform Services University (USU)
of the Health Sciences, Bethesda, Maryland; and professor of medicine at George
Washington University from 1975 until 1979 when he retired from the navy but
continued his position at USU [37–39]. Castell was chief of gastroenterology at
Bowman Gray School of Medicine at Wake Forest, North Carolina in 1982; Rohrer
Professor of Medicine and chief of the division of gastroenterology and hepatology
at Thomas Jefferson Hospital and Graduate Hospital in Philadelphia in 1989;
Kimbel professor and chairman of the Department of Medicine at the Graduate
Hospital of the University of Pennsylvania; and director of the esophageal disorders
program at the Medical University of South Carolina at South Carolina in 2001 [36,
37, 39, 40].
He was president of the American Gastroenterological Association (AGA) in
1999 [36, 38, 40]. From the AGA, he received the AGA Distinguished Teacher
Award, Kirsner Award for Clinical Research in 1992, Baker Presidential Leadership
Award in 1995, and Julius Friedenwald Medal [36]. He was recognized for his
excellence in teaching with the Outstanding Civilian Educator Award from USU
and Basic Science Teaching Excellence Award from Bowman Gray [36, 37, 39, 40].
A description of Castell’s character as articulated by Barbara Frank at his inau-
guration as the 92nd president of the AGA:
Now we will have the benet of his talents as a leader, not just his organizational and
administrative skills but his “people skills,” the warmth, sincere concern, rigorous honesty,
and enthusiasm that characterize his interactions with others and the insight and sound
judgment that he brings to difcult issues [37, p.1091].
8.2 Splenic Eponyms
286
Castell described a percussion method for determining the size of the spleen.
Percussion is performed using the middle nger of the left hand (Table 8.1,
Fig.8.2):
With the patient in the supine position percussion in the lowest intercostal space (eighth or
ninth) in the left anterior axillary line usually produces a resonance note if the spleen is
normal in size. Furthermore, the resonance persists with full inspiration. As the spleen
enlarges the lower pole of this organ is displaced inferiority and medially. This may produce
a chain in the percussion note in the lowest left interspace in the anterior axillary line from
resonance to dullness with full inspiration. The percussion note is considered positive,
therefore, when such a change is noted between full expiration and full inspiration [41,
p.1265].
Thus, Castell sign or the splenic percussion sign refers to a change in the percus-
sion note of the spleen between deep inspiration and expiration in the lowest left
intercostal space on the anterior axillary line when the patient is in the supine posi-
tion. Ten males with a positive percussion sign and ten controls underwent a spleen
scan. Castell found a positive concordance between a positive percussion sign and
slight to moderate degrees of splenic enlargement, as conrmed through a
spleen scan.
Fig. 8.2 Castell sign (by Ryan Yale)
8 Spleen Signs
287
8.2.10 Hedri Sign
Endre Hedri (1893–1962) was born in Gradiška, Bosnia and Herzegovina, and
received his medical degree from Semmelweis University in Budapest, Hungary
[42, 43]. His rst appointment after obtaining his medical certicate was as an assis-
tant in the Department of Surgery under the aegis of Manó Herczel (1862–1918) at
the Szent Rókus Hospital from 1914 to 1918, interrupted during World War I, where
he was a physician at the Gyáli út Garrison Hospital [42, 43].
Hedri was an assistant surgeon in Vienna, Leipzig, the surgical clinics of Kamiló
Vidákovits in Szeged, Hungary, from 1918 to 1923, and József Ferenc Pulmonary
Clinic in Budapest from 1924 to 1927 [42–44]. He was a clinical assistant professor
at Országos Társadalombiztosítási Intézet (OTI) at the Ursoki Utcai Kórház Hospital
from 1927 to 1933 and chief physician of Baleseti Sebészeti Osztályának from 1933
to 1945 [44].
Hedri was a chief trauma surgeon at OTI Baleseti Sebészeti Kóháza Hospital
from 1945 to 1947 and a public professor of Trauma Surgery at Pázmány Péter
University and Budapest Medical University, the latter of which he was appointed
professor in 1952 [44]. He was a director of the third surgical clinic at Koltói Anna
Baleseti Kórházban from 1947 to 1949 and director of the rst surgical clinic at
Budapest Medical University from 1949 to 1962 [42, 44]. Hedri was a correspond-
ing member of the German Surgical Society, recipient of an honorary doctorate
from the University of Leipzig, and president of the Sándor Korányi Society [44, 45].
As a tribute to Hedri’s life by Babics:
We thank him for his tireless zeal, the exemplary care he gave to his patients, the enthusi-
asm with which he devoted himself to promoting scientic life, and the boundless diligence
with which he always worked to solve the most complex surgical problems [45, p.1].
His character as described by Zsebök:
One of his most characteristic qualities is his concern for patients. He was a humanist, a
good man, for whom surgery was only a means to be his fellow man; help him with the most
concrete tools of medicine and the methods of surgical intervention. This ability to help
drove him to take on many, often almost impossible, surgical tasks. Even in the most chal-
lenging moments of life, he remained a human being whose main law was to help others
[44, p.2306].
Keleman, in his book Physical Diagnosis of Acute Abdominal Diseases and Injuries,
described Hedri’s sign of thoracic compression:
[p]ressure of the sternum elicits pain in the left costal arch in splenic rupture; whereas pain
in the right costal arch indicates liver injury. This is a particularly valuable sign in differen-
tiating non-penetrating injuries causing abdominal hemorrhage if fracture of the lower ribs
can be excluded [46, p.94].
Thus, Hedri sign is the method for determining splenic rupture or hepatic injury.
8.2 Splenic Eponyms
288
8.3 Summary ofBedside Methods toDetermine Spleen Size
Direct (single-nger) and mediate (two-nger) techniques have been used to per-
cuss the spleen to determine its size. The authors typically position the patient in the
supine position. Hoover (1901) recommended using a direct technique in which
“the patient should lie on his back so as to bring the spleen in intimate contact with
the ribs. The lower border of the lung in the posterior axillary line is rst determine
and then percuss gently in the intercostal space toward the median line at right
angles to the costal border” [47]. A study compared splenic percussion (Nixon and
Castell) with palpation using scintigraphy as the gold standard to conrm splenic
enlargement (≥12cm in length and/or >7cm in width). The sensitivity and specic-
ity were for Nixon (59%, 94%), Castell (82%, 83%) and palpation (71%, 90%) [48,
49]. Combining both palpation and percussion techniques identied, up to 88% of
spleens were enlarged by scintigraphy [48]. In a comprehensive review of prior
studies on the splenic percussion sign, a sensitivity of 25–85%, specicity of
32–94%, positive likelihood ratio of 1.7, and negative likelihood ratio of 0.7 were
identied for Castell sign, and a sensitivity of 25–66%, specicity of 68–95%, posi-
tive likelihood ratio of 2.0, and negative likelihood ration of 0.7 for Nixon sign. In
contrast, the sensitivity, specicity, and likelihood ratio for detecting an enlarged
spleen by palpation were 18–78%, 89–99%, 8.5, and 0.5, respectively [49]. A false
negative percussion sign may occur in patients with marked splenomegaly or uid
in the stomach or stool in the adjacent colon. Palpation is more likely to detect
splenic enlargement than percussion techniques.
There is poor intraobserver agreement using percussion alone to measure spleen
size. Applying a strategy that incorporates pre-test clinical suspicion of splenomeg-
aly improves the performance of the test and provides a rationale for obtaining an
ultrasound to conrm splenic enlargement [50, 51
]. Using this strategy, if the pre-
test probability is <10%, neither percussion nor palpation is sufciently sensitive to
rule out splenomegaly, and the specicity is not sufciently high to rule in spleno-
megaly. If the clinical suspicion is >10%, then percussion and palpation can rule in
splenomegaly. If either percussion or palpation, but not both, detects an enlarged
spleen, an ultrasound is recommended to conrm spleen size. Because of the lower
sensitivity of percussion or palpation, an ultrasound is required to rule out spleno-
megaly [50, 51].
Table 8.1 Splenic eponyms
Name Year Description of eponym Signicance
Debove [8] 1892 Splenomegaly, hypertrophy, or an increase in spleen
volume
Portal
hypertension
Pitts [11] 1896 Fixed dullness in the splenic region Splenic
rupture
Ballance
[18]
1898 Fixed dullness in the left ank Splenic
rupture
(continued)
8 Spleen Signs