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289
Table 8.1 (continued)
Name Year Description of eponym Signicance
Pagniello
[19]
1920 Moderate pressure is applied at the ninth left intercostal
space between the midline and posterior axillary line using
the index or middle nger of the right hand. The patient
reports a painful sensation located at this point associated
with a reex muscular contraction of the trunk or face, or
the patient tells you that they are experiencing pain. Pain
may also rarely occur when pressure is applied at the
eighth, ninth, or tenth intercostal space. In patients
sensitive to pain, it is best to cautiously apply this
maneuver, using the entire palm 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
Malaria
Castronuovo
[22]
1927 The spleen is soft, so a non-painful imprint occurs when
palpating this organ
Splenic
hyperemia
Sailer [27] 1928 Splenic pulsation Aortic
insufciency
Saegesser
[33]
1938 Pressure is applied with the thumb of the right hand
posteriorly on the left side of the neck between the
sternocleidomastoid and anterior scalene muscles and
directed toward the larynx and spine. The phrenic nerve
pressure point on the right side is evaluated using the same
hand movement. A positive sign is the presence of left
shoulder pain
Splenic
rupture
Nixon [35] 1954 The patient is placed in the right lateral recumbent
position with the left arm extended forward and upward
sufciently to clear the left lower part of the thorax. After
palpation to identify the lower border on inspiration,
percussion is initiated at the lower level of pulmonary
resonance in approximately the posterior axillary line and
moved downward obliquely on a general perpendicular
line toward the lower mid-anterior costal margin.
Normally the upper border of dullness measures 6–8cm
above the costal margin. Dullness extending over 8cm is
indicative of splenic enlargement in the adult
Splenomegaly
Castell [41] 1967 With the patient supine, percuss in the lowest intercostal
space (eighth or ninth) in the left anterior axillary line. A
resonance note is present and persists throughout
inspiration if the spleen is normal in size. As the spleen
enlarges, the lower pole of this organ is displaced
inferiority and medially causing further dullness on
percussion in the lowest left interspace during full
inspiration. The test is positive if percussion dullness is
present over a larger area on full inspiration compared to
full expiration
Splenomegaly
Hedri [46] [n.a.] Pressure over the sternum causes pain at the left costal
arch
Splenic
rupture
8.3 Summary of Bedside Methods to Determine Spleen Size
290
8.4 Conclusion
Signs of the spleen were identied prior to the advent of advanced imaging tech-
niques, including ultrasonography which can now detect splenic enlargement, rup-
ture, and portal hypertension at the bedside. They remain of historical interest as
they provide insight into the discovery of novel methods used for diagnosing dis-
ease. The physical examination is moderately sensitive but nonspecic in detecting
splenomegaly. Thus, its absence does not exclude the presence of disease. The
examination should still be taught as splenic enlargement, or other maneuvers used
to detect conditions involving the spleen assist in diagnosis when used concomi-
tantly with other clinical aspects of disease.
References
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2. Malpighii M.De liene praefatio. In: De viscerum structura exercitatio anatomica. Amsterdam:
Apud Petrum Le Grand; 1669. p. 96–145.
3. Kölliker A.Vessels of the spleen. In: A manual of human microscopic anatomy. London: John
W.Parker and Son; 1860. p. 358–72.
4. [No author]. Décès de M.Debove, secrétaire perpétuel. Bull Acad Méd. 1920;84:238–42.
5. Delmas V, Achard C, Janes J.Debove George Maurice. Comité Trav Hist Sci. http://cths.fr/an/
savant.php?id=105493. Accessed 25 Nov 2022.
6. [No author]. Professor G.M.Debove. Br Med J. 1920;2:955.
7. Cherrington EH.Georges Maurice Debove. In: Standard encyclopedia of the alcohol problem,
vol. 2. Westerville, OH: American Issue Publishing Company; 1924. p. 775.
8. Debove GM.De la splénomégalie primitive. France Méd. 1892;30:506–7.
9. Pitts B.Plarr’s lives of the fellows. London: Royal College of Surgeons of England; 2012. https://
livesonline.rcseng.ac.uk/client/en_GB/lives/search/detailnonmodal/ent:$002f$002fSD_
ASSET$002f0$002fSD_ASSET:375144/one?qu=%22rcs%3A+E002961%22&rt=false%7
C%7C%7CIDENTIFIER%7C%7C%7CResource+Identier. Accessed 3 Nov 2022.
10. [No author]. Bernard Pitts, MC, FRCS, consulting surgeon to St. Thomas’s Hospital and to the
Hospital for Sick Children, Great Ormond Street. Br Med J. 1914;2:1122–3.
11. Pitts B, Ballance CA.Three cases of splenectomy for rupture. Clin Soc. 1896;29:77–104.
12. [No author]. Sir Charles Ballance, KCMG, CB MS, FRCS.Br Med J. 1936;1:339.
13. Elsberg CA.Obituary: Charles Alfred Ballance, 1856–1936. Bull N Y Acad M. 1936;12:146–9.
14. Ballance CA. Plarr’s lives of the fellows. London: Royal College of Surgeons of Eng-
land; 2013. https://livesonline.rcseng.ac.uk/client/en_GB/lives/search/detailnonmodal/
ent:$002f$002fSD_ASSET$002f0$002fSD_ASSET:375978/one?qu=%22rcs%3A+E00379
5%22&rt=false%7C%7C%7CIDENTIFIER%7C%7C%7CResource+Identier. Accessed 20
Nov 2022.
15. Manché A.Sir Charles Ballance: a pioneer surgeon in Malta. Malta Med J. 2014;26:56–9.
16. Turner A. Ballance, Sir Charles Alfred (1856–1936). London: Royal College of Surgeons of
England; 2008. https://aim25.com/cats/9/9914.htm. Accessed 20 Nov 2022.
17. [No author]. Sir Charles Ballance, KCMG, CB, MVO.Nature. 1936;137:350.
18. Ballance CA. On splenectomy for rupture without external wound. Practitioner.
1898;60:347–58.
19. Pagniello R.Medio fácil y rápida para el diagnóstico de la infección malárica. Sem Méd.
1920;27:830–1.
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20. Tomasulo B.Giovanni Castronuovo. La Basilicata nel Mondo. 1924;1:212–3.
21. [No author]. Giovanni Castronuovo. Rome: Bollettino Ufciale del Ministero della Istruzione
Pubblica; 1907. p. 2504.
22. Castronuovo G.Milza plastica o malleabile nell’anemia broadenica, tipo Griesinger-Banti.
Riforma Med. 1927;43:554.
23. Riesman J.Joseph Sailer. Am J Surg. 1929;7:576–8.
24. [No author]. Joseph Sailer. Am Heart J. 1929;6:367–8.
25. [No author]. AHA elections. Bull Am Heart Assoc. 1928;3:5.
26. [No author]. Former ofcers: President Joseph Sailer. Annu Meet Am Gastroenterol Assoc.
1926;28:8.
27. Sailer J.Pulsating spleen in aortic insufciency. Am Heart J. 1928;3:447–53.
28. Yale SH, Tekiner H, Mazza JJ, Yale ES, Yale RC.Aortic regurgitation murmurs. In: Cardio-
vascular eponymic signs: diagnostic skills applied during the physical examination. Cham:
Springer; 2021. p. 105–42.
29. Gerhardt C.Pulsierender Milztumor. Ztschr klin Med. 1882;4:449–50.
30. Saegesser M. (16 Feb 1902–17 Oct 1975). Google arts & culture. https://artsandculture.
google.com/entity/g1215vkg6?hl=es. Accessed 12 Nov 2022
31. Weisser C.Max Saegesser. In: Chirurgenlexikon: 2000 Persönlichkeiten aus der Geschichte
der Chirurgie. Berlin: Springer; 2019. p. 281.
32. Vierhaus R.Max Saegesser. In: Deutsche biographische Enzyklopädie. Munich: K.G.Saur;
2005. p. 669.
33. Saegesser M.Der linksseitige Phrenikusdruckpunkt als diagnostisches Merkmal bei Milzver-
letzungen. Zentralbl Chir. 1938;65:2179–80.
34. Priest RJ, Robert K.Nixon. Henry Ford Hosp Med J. 1996;34:291–2.
35. Nixon RK Jr. The detection of splenomegaly by percussion. NEJM. 1954;250:166–7.
36. Richter JE, Katz PO, Katzka DA.In memoriam: Donald O.Castell, MD.Gastroenterology.
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37. Frank BB.Our new president: Donald O.Castell, MD.Gastroenterology. 1998;114:1091–4.
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mentoring, and education. Am J Gastroenterol. 2021;116:444.
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40. Rattan S, Cao W, Katz PO, Goyal RK.In memory of our following colleagues, and friends. J
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1967;67:1265–7.
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43. Endre H.Nemzeti Örökség Intézete. https://intezet.nori.gov.hu/nemzeti-sirkert/budapest/far-
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44. Zsebök Z.Hedri Endre Dr. (1893–1962). Orv Hetil. 1962;103:2305–6.
45. Babics A.Prof. Endre Hedri (1893–1962). Acta Chir Acad Sci Hung. 1963;4:1.
46. Keleman E.Physical diagnosis of acute abdominal diseases and injuries. Budapest: Akadémiai
Kiadó; 1964.
47. Hoover CF.The diagnosis of typhoid fever. Cleve Clin J Med. 1901;6:5–8.
48. Sullivan S, Williams R.Reliability of clinical techniques for detecting splenic enlargement. Br
Med J. 1976;2:1043–4.
49. McGee SR. Evidence-based physical diagnosis. 3rd ed. Philadelphia, PA: Elsevier; 2012.
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50. Grover SA, Barkun AN, Sackett DL. Does this patient have splenomegaly?
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293© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2023
S. H. Yale et al., Gastrointestinal Eponymic Signs,
https://doi.org/10.1007/978-3-031-33673-7_9
Chapter 9
Pancreas Signs
9.1 Introduction
While a clinical description of acute pancreatitis was rst presented in the seven-
teenth century by Nicolaes Tulp (1593–1674), the word pancreatitis is believed to
have rst appeared in the literature by Robley Dunglison (1798–1869) in 1842, but
clearly, the disease had been further described as early as 1804 by Antoine Portal
(1742–1832) [1, 2]. Felix Victor Birch-Hirschfeld (1842–1899) described chronic
pancreatitis in 1895, while Reginald Heber Fitz’s description of acute suppurative
gangrenous hemorrhagic pancreatitis with fat necrosis presented at the NewYork
Pathological Society in 1889 remains notable even today [3, 4]. Fitz’s paper brought
attention to the signicance of this gland, including its frequency, pathology, and
treatment. His name is eponymously ascribed in honor of his description of the
clinical features of acute pancreatitis and thus, in the strictest sense, represents
symptoms and not a sign [4].
There are few signs of acute and chronic pancreatitis, presumably due to the
limited access of this organ to palpation and percussion. With the advent of radio-
graphic imaging, other patterns and associated ndings in acute pancreatitis were
recognized, including isolated dilation of the transverse colon by Josef Goblet in
1913 and the “inverted gure 3” sign by Nils Frostberg in 1938. Furthermore, their
role in clinical practice is unknown since they have never been studied. We present
these signs as a tribute to their keen observation and meticulous examination tech-
niques to better dene the diseases of acute and chronic pancreatitis.
294
9.2 Eponymic Signs
9.2.1 Fitz Sign
Reginald Heber Fitz (1843–1913) was born in Chelsea, Massachusetts, USA.He
was a house ofcer at Boston City Hospital in 1867 and received his medical degree
from Harvard Medical School in 1868 [5–7]. He continued his studies abroad pri-
marily with Rudolph Virchow (1821–1902) in Berlin; Carl von Rokitansky
(1804–1878), Johann Ritter von Oppolzer (1808–1871), and Joseph Škoda
(1805–1881) in Vienna; Victor André Cornil (1837–1908) in Paris; and Charles
Murchison (1830–1879) in London [5–10].
Fitz served in Boston as an instructor in pathological anatomy at the Harvard
Medical School from 1870 to 1873, was a physician to the Boston Dispensary, a
microscopist at Massachusetts General Hospital in 1871, and assistant professor of
pathology from 1873 to 1878 and chair of pathological anatomy at Harvard Medical
School in 1878 (renamed Shattuck Professor of Pathological Anatomy in 1879) [5,
6, 9, 10]. He was appointed visiting physician to the Massachusetts General Hospital
in 1887 and Hersey Professor of the Theory and Practice of Physic at Harvard
Medical School in 1892 [5, 9, 10].
Among his numerous accolades, Fitz was elected fellow of the American
Academy of Arts and Sciences, associate fellow of the College of Physicians in
1892, honorary member of the Medical and Chirurgical Faculty of Maryland in
1893, and honorary fellow of the NewYork Academy of Medicine. He received an
honorary degree of L.L.D. from Harvard College in 1905 [5]. He was president of
the Association of American Physicians in 1894 and was elected corresponding
member of the Gesellschaft für innere Medizin und Kinderheilkunde (Society of
Internal Medicine and Pediatrics), Vienna, and president of Congress of American
Physicians and Surgeons in 1907 [5, 8].
As to his character as described by Stone:
The work that Dr. Fitz has done during his active period of life has been largely critical and
judicial, though always with a constructive tendency. He has formed his opinions for himself,
and then bravely stood by them, even at times when they were in opposition to those of a
majority of his friends or to the potent inuence of the president of the university [11, p.12].
Fitz, in his Middleton-Goldsmith Lecture on patients with acute suppurative pancre-
atitis, delivered before the NewYork Pathological Society in 1889, described the
symptoms found in this disease:
The cases of acute, suppurative pancreatitis usually began suddenly, with severe generally
intense, gastric, epigastric or abdominal pain, vomiting, and sometimes great prostration.
The vomiting might be incessant and distressing, or it might give temporary relief to the
pain. The ejected uid was sometimes stringy and brown. The bowels were usually consti-
pated, although diarrhea might occur within the rst twenty-four hours. This latter symp-
tom was not infrequent at a later date of the disease. Fever usually slight, was the next
conspicuous symptom, being manifested about the third day. At the same time the upper
abdomen, especially the epigastrium, was likely to become distended, tympanitic, and sen-
sitive. Hiccough, sometimes quite obstinate, was not infrequent at this state, and occasion-
ally chills were to be met with. The abdomen, in general, then became moderately swollen,
tense, and tympanitic [4, p.56].
9 Pancreas Signs
295
Thus, Fitz enumerated the symptoms of acute pancreatitis, which include the sud-
den onset of severe vomiting, epigastric abdominal pain, and abdominal swelling
(Table9.1).
9.2.2 Körte Sign
Werner Friedrich Emil Körte (Koerte) (1853–1937) was born in Berlin, Germany,
studied medicine in Berlin, Bonn, and Strasburg, and received his medical degree in
1857 [12, 13]. He was an assistant at the University Surgical Clinic from 1874 to
1876 and Max Wilms (1867–1918) at the Bethanien Hospital, Berlin, from 1877 to
1879 [13, 14]. Körte was director of the surgical division of Städtisches Krankenhaus
am Urban zu Berlin (Berlin Urban Hospital) from 1889 to 1924 [12–14]. During
World War I, he was a consultant to the Third Reserve Corps. At Berlin University,
he was a Geheimer Sanitätsrat (honorary title of Privy Medical Advisor) and titular
professor [13].
Körte was a recipient of the Iron Cross (rst class) for his valor during World War
I, president of Deutsche Gesellschaft für Chirurgie (German Society of Surgery),
and president and honorary chairman of Berliner Gesellschaft für Chirurgie (Berlin
Society for Surgery) [12–14].
As to a description of his character by Brentano:
He was a brilliant orator who surprised his audience, lecturing with clarity and conciseness
and socially with wit and spirit. (…) He possessed a warm, gentle, virtuous heart not always
hidden under a rough shell. This heart corresponded to an unsurpassable love of truth,
which he found expression in his scientic work and everyday life, making it so valuable
[15, p.1923].
Körte described his experience with palpation of the pancreas in cases of acute
pancreatitis:
A symptom that conrms the diagnosis beyond the realm of suspicion and is of major inter-
est for surgical treatment is feeling a tumor in the epigastrium at the site of the pancreas.
Due to its protected position, the organ is not easily accessible for palpation. However, it is
possible to feel the gland and its granular structure in the epigastrium in front of the spine
if the abdominal wall is relaxed and not obese and the stomach and intestines are empty [16,
p.153]. Only when epigastric distension has subsided or eliminated by gastric lavage and
when the tension in the abdominal muscles is overcome after reducing the pain or using
anesthesia can the swollen organ be felt. After the stomach and intestines have been emp-
tied, possibly under anesthetic, can a tumor be observed in the epigastrium, corresponding
to the location of the pancreas. In that case, it must be borne in mind that there remain vari-
ous possibilities for error. (…) After the stomach is reduced, it can be established that the
mass is felt behind the stomach, but it cannot be ruled out that it originates from the poste-
rior wall of the stomach. Complete certainty that the tumor is felt in the pancreas cannot be
achieved in all cases, nor can it be determined with certainty after the pus has erupted
whether the resistance felt lies in the pancreas or is located either retroperitoneally or intra-
peritoneally in the omental bursa. As a rule, the swelling can only be felt when the acute
stage of the disease is over and the pain and distention of the epigastrium have subsided. If
one feels resistance in the epigastrium behind the stomach or between the stomach and
colon in patients who present the clinical picture outlined above, then one can consider the
diagnosis of pancreatitis [16, p.154].
9.2 Eponymic Signs
296
Thus, Körte sign refers to the palpable epigastric mass in patients with acute pancre-
atitis (Table9.1).
9.2.3 Halsted Sign
William Stewart Halsted (1852–1922) was born in NewYork City, USA, received
his medical degree from Columbia University College of Physicians and Surgeons
(currently Columbia University Vagelos College of Physicians and Surgeons),
NewYork, in 1877, and was an intern at the fourth surgical division at Bellevue
Hospital [17–20]. He traveled abroad for twoyears to Vienna, Leipzig, and Würzburg
in 1878 to further his medical training [18–20]. He served as a demonstrator of
anatomy at the College of Physicians and Surgeons and established the outpatient
department at Roosevelt Hospital in 1880 [18, 21]. Halsted was appointed rst at the
Charity Hospital as attending surgeon and director of the outpatient departments
from 1881 to 1887, surgeon-in-chief to Emigrant Hospital Ward’s Island, and visit-
ing physician to Bellevue and Presbyterian Hospitals from 1885 to 1887 [19, 21].
He worked at William Henry Welch’s (1850–1934) Laboratory at Johns Hopkins
University, followed by appointments as associate professor of Surgery, head of the
outpatient department, acting surgeon to the hospital in 1889, surgeon-in-chief in
1890, and professor of surgery in 1892 at Johns Hopkins Hospital [18, 19].
As described his character by MacCallum:
In attempting to estimate the signicance of Dr. Halsted’s work it seems that his greatest
service was not so much his surgical discoveries and inventions, many and important as
these were, as his attitude in operating upon the human body which must forever be the
proper attitude of the surgeon. It was simply the recognition of the normal or physiological
condition of the tissues which one should attempt to restore, realizing their natural defense
and the reasons for their vulnerability. (…) He was not inated with self-esteem, he did not
advertise and he was not a politician, the things which lead to present but not to permanent
fame. But he made lasting contributions to the world’s knowledge and his name will endure
[19, p.162].
As reported in an obituary in the California State Journal of Medicine:
This philosopher-surgeon was ever intent on extending the bounds of medical knowledge,
and devoted himself whole-heartedly to qualifying and enriching the minds of his many
pupils. We are grateful for this legacy, which he so bountifully distributed during his life-
time, “teaching what he had learned, and learning in order that he might teach.” We glory in
his tireless energy, his quiet, simple and unostentatious manner, and in the splendid accom-
plishment of his many tasks. He was truly a great man, a daring and brilliant pioneer of
surgery, and his single-hearted and self-sacricing devotion to the cause of scientic
research had its reward in achievements of the most vital and far-reaching nature [22,
p.420].
Halsted made signicant contributions to surgery, with those most highly coveted
involving the surgical management of breast cancer, use of rubber gloves, inguinal
herniorrhaphy, thyroid and parathyroid glands, and subclavian artery aneurysms. He
9 Pancreas Signs
297
is the recipient of several honorary degrees, including the L.L.D. from Yale (1904)
and Edinburgh (1905) as well as a D.Sc. from Columbia (1904) University [17, 21].
Additionally, he was an honorary fellow of the Royal College of Surgeons of
England and Edinburgh [17, 21].
Halsted, in his description of a case of acute hemorrhagic pancreatitis involving
an 18-year-old male, described on physical examination that:
He was sensitive to pressure over the epigastrium, but not exquisitely, the point of greatest
tenderness being a little above and, I thought, to the right of the umbilicus. (…) I have
thought that it might be well to represent graphically the only sign which this obscure case
presented, the white print of the ngertips in a slightly cyanosed eld just over the site of
greatest pain [23, p.180].
Thus, Halsted sign refers to the blanching of the skin when the ngertip is applied
to the cyanotic abdomen in patients with hemorrhagic pancreatitis (Tab le9.1).
9.2.4 Mayo-Robson Sign
Sir Arthur William Mayo-Robson (1853–1933) was born at Filey, Yorkshire,
England, studied at Leeds School of Medicine and received his membership of the
Royal College of Surgeons in 1874 and licentiate of the Royal College of Physicians
in 1875 [24]. He was appointed demonstrator in anatomy and lecturer from 1876 to
1886 at Leeds School of Medicine. He was a fellow of the Royal College of Surgeons
in 1879 [24–26]. Mayo-Robson was appointed assistant surgeon in 1882 and sur-
geon in 1884 to the General Inrmary, Leeds, followed by professor and chair of
surgery at Yorkshire College (Victoria University) from 1890 to 1899 [25, 26].
During World War I, he was consulting surgeon to the Mediterranean Expeditionary
Force with the rank of temporary lieutenant colonel Royal Army Medical Corps
stationed in Egypt and Gallipoli in 1915 [24, 26]. He served as a consultant to the
medical counsel of the Southern Command Ward Ofce in 1917, as inspector of the
Military Orthopedic Hospital in London in 1918, followed by consulting surgeon to
the King Edward VII Hospital, Windsor and Dreadnought Hospital, Greenwich
[24, 26].
Mayo-Robson served as president of the British Gynecological Society and
Leeds and West Riding Medico-Chirurgical Society, vice-president of the Royal
College of Surgeons, and member of the British Medical Association [24, 25]. He
was knighted in 1908, Knight Commander of the Order of the British Empire in
1919, and Companion of the Royal Victorian Order in 1911 [24, 25].
As to a tribute to his character as articulated by Moynihan:
He possessed industry the like of which I have seen matched in only one other among those
with whom I have worked. He had a radiant, quenchless enthusiasm. His capacity for seiz-
ing upon relevant features in a new problem, of capturing the essential principle, and
neglecting specious non-essentials seemed like wizardry. All these qualities and many more
were at once in his service [27, p.948].
9.2 Eponymic Signs
298
Mayo-Robson described in patients with pancreatitis:
The more acute inammations are characterized by excessive tenderness on pressure, the
presence of a tender spot just above and to the right of the umbilicus, rigidity of the recti,
and pain of an agonizing character [28, p.314].
Thus, Mayo-Robson sign refers to pain in acute pancreatitis above and to the right
of the umbilicus (Table9.1).
9.2.5 Löwi Sign
Otto Löwi (Loewi) (1873–1961) was born in Frankfurt am Main, Germany, and
received his medical degree from the University of Strasburg in 1896 [29–32]. He
worked with Hans Horst Meyer’s (1853–1939) Laboratories at the Pharmacologic
Institute at the University of Marburg, continuing his work with Meyer in Vienna
from 1898 to 1908 [30]. During this period, he was appointed and rose to the rank
of assistant and associate professor [30]. He served as a lecturer in pharmacology in
Marburg in 1900, was appointed extraordinary professor in Vienna in 1904, and was
chair of pharmacology at the University of Graz, Austria, in 1909 [30, 32]. He is
best recognized for his work on the autonomic nervous system and the role of the
vagus, acetylcholine release, and sympathetic nerves in the heart [32]. He and Sir
Henry Hallett Dale (1875–1968) were awarded the Nobel Prize in Physiology and
Medicine in 1936 [29–31, 33]. He was imprisoned by the Nazis in 1938, ed
Austria, and served as a visiting professor at the Free University of Brussels and the
Nufeld Institute in Oxford [29, 31, 33]. While in England, he received an appoint-
ment as a research professor in pharmacology from NewYork University College of
Medicine in 1940 [29, 30].
As to a description of his character:
A man with an irrepressible zest for life, thoughtful optimism, and sense of humor. These
surely are some of the outstanding traits which comes to mind to the many friends who
knew Otto Loewi. (…) A chance meeting with Otto Loewi could be a memorable occasion.
One drew readily a spark of enthusiasm from his ever-searching mind. His eyes would
shine, his remarkable kaleidoscopic face would light up as he took hold of ideas and devel-
oped them [29, p.451].
Löwi received numerous awards, honorary degrees, and memberships throughout
his career, recognizing his outstanding accomplishments and contributions to physi-
ology and medicine. His image was honored through a stamp issued in Austria in
1973in recognition of the centenary of his birth [33, 34].
Löwi presented a nding at the Vienna Medical Society in 1907in patients with
pancreatic insufciency:
By injecting a solution of adrenaline into the conductive sac of animals whose pancreas had
been removed, he observed a marked pupillary mydriasis, which he never found in the
control animals. [I]n healthy individuals, installing a few adrenaline drops never produced
any phenomenon. However, in patients with diabetes, it produces marked pupillary mydria-
sis [35, p.934].
9 Pancreas Signs
299
Löwi believed that mydriasis occurred due to the absence of nerves that inhibits pupil-
lary dilation. Thus, a positive Löwi sign is the presence of marked pupillary mydriasis
after the installation of three to four drops of adrenaline into the conjunctival sac in
patients with diabetes mellitus caused by pancreatic insufciency (Tab le9.1).
9.2.6 Goblet Sign
We could only identify limited historical information on Josef Goblet (1878–1944).
At the time of his publication titled “Beiträge zur akuten Pankreasnekrose”
(Contributions to acute pancreatic necrosis), he was a surgical ordinary at the
Gewerkschaftlichen Krankenhause (Union Hospitals) in Orlau, Czech Republic [36].
Goblet described a nding in pancreatic necrosis:
In my experience, I observed in my rst published case isolated distension of the transverse
colon, I have already discussed its possible signicance as an early symptom of acute pan-
creatic necrosis prompting von Faykiss to designate the name Goblet’s symptom. (…)
Based on my observations and the perceptions of other authors, I have to emphasize again
that isolated distension of the transverse colon represents an early symptom of acute pan-
creatic necrosis, which in the absence of other symptoms, is characteristic of pancreatic
necrosis [36, p.1387].
Thus, Goblet sign refers to the gaseous distension (meteorism) of the transverse
colon in acute pancreatic necrosis (Table9.1).
9.2.7 Frostberg (Inverted 3) Sign
Nils Johan Frostberg (1905–1972) was born in Lund, Sweden, and received his
medical license in 1934 [37]. He was chief physician of the Provincial (District)
Hospital in Hässleholm, Sweden, in 1949 and senior physician in the Department of
Radiology at Kristianstad, Sweden, in 1957 [37].
Nils Frostberg summarized the radiographic ndings in three cases of pancreatic
carcinoma and other inammatory conditions involving the head of the pancreas:
The author is recording three cases of a similar and peculiar deformity of the descending
part of the duodenum, assuming the shape of an inverted gure “3”. On the strength of the
radiographic examination, growths in the head of the pancreas were considered the most
probable explanation. However, autopsy ndings have shown that pancreatitis and edema
may also give rise to such deformities [38, p.172].
Thus, Frostberg sign refers to the radiographic appearance seen on barium examina-
tion of the small bowel whereby there are two adjacent rounded or bud-shaped
depressions involving the concave portion of the descending portion (second part)
of the duodenum (Table 9.1). This radiographic nding represents an inltrative
process that distorts or effaces the mucosal pattern on the medial wall of the duode-
num originating from the head of the pancreas due to tumor, edema, inammation,
or duodenal carcinoma [39].
9.2 Eponymic Signs