Circular Folds Research Articles

On Innervation, Especially, Sensory Innervation of the Pars Pylorica, the Duodenum, the Ductus Choledochus and the Pancreas in Cat

In the pars pylorica of cat, the tunica muscularis is much better developed than the same of the duodenum, but as the pylorus is approached, its outer longitudinal layer becomes mach worse developed, sometimes to utter deficiency, in the dorsal side. In the proximal part of the duodenum the outer layer of the muscularis is likewise very ill developed. In the pars pylorica many longitudinal mucous folds are in formation but in the duodenum such folds are almost absent. The villi intestinales of the duodenum are much lower but the crypts are much longer in cat than in man. The duodenal glands are much poorer in development in cat than in hedgehog, and become even worse developed gradually distalwards, utterly going out below the level of the opening of the ductus choledochus. Upon approaching the duodenum, the ductus choledochus comes to be surrounded by a tunica muscularis originating in the duodenal muscularis. This muscularis, however, unlike in the case of duodenum, consists here of an outer circular and an inner longitudinal layers. The part of the choledochus running through the duodenal wall is provided by a lamina muscularis mucosae, which makes transit into that of the duodenum.In the pars pylorica of cat the AUERBACH's plexus is much better developed than in the duodenum, and wat is of interest, ganglia are found here and there in the well-developed inner circular muscle layer of the pars pylorica, and small ganglia are found in sporadic existence in the outer longitudinal layer of the duodenum as well. MEISSNER's plexus is formed in the mucous folds of the pars pylorica, containing some small ganglion cells, but since in the duodenum, no circular folds are found, the plexus is far more inferior in development, ganglion cells being only rearly seen therein. The ganglion cells in the AUERBACH's and the MEISSNER's plexus, showing multipolarity and sometimes distinguishable into the DOGIEL's Type I and Type II, belong to the category of sympathetic cells. Sometimes, however, infantile cells of apolar type are also found. The vegetative fibres always end in STOHR's terminal reticula in the muscularis, the submucosa and the mucous membrane too, coming into control by contact over the supplied cells.Sensory fibres, partly originating in the nn. splanchnici but more often in the n. vagus are found running into the pars pylorica in the case of cat too, seemingly somewhat larger in number than in the case of man. These fibres end in unbranched and simple branched terminations in the propria mucosae. Their terminal fibres often show marked change in size and wavy courses and end in sharp points, not rarely running up to the bases of the epithelium and the pyloric glands but never into them.Into the duodenum of cat are found running some sensory fibres originating in nn. splanchnici, in a quantity larger than those coming into the pyloric part. The number of their terminations is the larger, the more cranial the position in the duodenum, where the duodenal glands are also better developed, diminishing rather drastically in its caudal part. This finding would be sufficient in suggesting the importance of the reflex act stimulating secretion from the duodenal glands in connection with the digestive function. These terminations are partly formed in the submucosa but in most part in the propria. Their terminations, quite as in the pars pylorica, consist in unbranched and simple branched types, but are much more spaciously diffused and comprise some branched terminations a little more complicated than those in the pyloric part. No more complex formations, such as glomerular terminations, were found either in the pars pyiorica or the duodenum of cat.In the muscularis in the caudal part of the ductus choledochus of cat is found AUERBACH's plexus containing ganglion cells like those in the stomach and the duodeuum. The vegetative fibres end in terminal reticula here too.

The roentgen manifestations of relapsing pancreatitis.

Relapsing pancreatitis is a disease of recurring exacerbations separated by varying intervals of seemingly relative clinical quiescence. At any given time it represents the summation of all previous episodes. In recent years, the pathologists have increasingly emphasized the continuing, chronic, relapsing, and progressive nature of this disease as well as its varied manifestations and associated conditions. The clinicians, also, now clearly recognize relapsing pancreatitis as a distinct entity, even though it is a complex syndrome with many aspects. Its presence may be difficult to detect, or even suspect, since the clinical picture may vary in the history of any one patient. Especially is this true in the subclinical phases. Facts relating to etiology, pathogenesis, sex, age, the role of obesity, alcohol, trauma, common channel, infection, etc., have been well covered by Doubilet and Mulholland (5 and 6) and need no further elaboration. The roentgen manifestations of relapsing pancreatitis can be divided into two groups: (1) those indicating an acute or a subacute exacerbation and (2) those indicating chronic pancreatitis. 1. Roentgen Manifestations of an Acute or Subacute Exacerbation Roentgen Manifestations Which Involve the Duodenum: Inasmuch as relapsing pancreatitis is a continuing and progressive disease, it is important to detect new episodes as early as possible. The papillary sign (8) is the earliest roentgen indication of a sudden subacute or acute exacerbation.2 Laboratory data have been overemphasized (3) and the usual roentgen signs appear too late. Anatomic studies (8) have provided basic information concerning the size, shape, and position of the vaterian papilla in health and disease. In the course of relapsing pancreatitis it was noted, during a gastrointestinal series, that very early in the relapse the papilla became enlarged as the result of edema, even before pancreatic swelling could be detected. If the inflammatory condition was severe, the edema spread from the papilla as a center and involved the contiguous duodenal mucosa in all directions. The papillary enlargement, however, at the center, was always the greatest. This papillary edema reflected the underlying inflammatory condition, increasing and decreasing almost daily with the degree of inflammation. Its recognition in a case of known chronic pancreatitis is pathognomonic of a relapse. In other instances, it at least indicates a regional inflammatory condition. The next roentgen manifestation may be a functional disturbance in the duodenum. This may take the form of a change in motility (usually an increase), altered peristalsis, the presence of retroperistalsis, localized evanescent areas of spasm, intolerance to barium, and modification of the usual pattern of barium distribution. The valvulae conniventes, which normally have a continuous uniform appearance, may show skipped areas free of barium.

Hepatodiaphragmatic interposition of the small intestine.

The presence of gas between the liver and the diaphragm poses the differential diagnosis of pneumoperitoneum from a perforated viscus, subdiaphragmatic abscess, and intestinal hepato-diaphragmatic interposition. Colonic hepato-diaphragmatic interposition has been frequently reported. Small intestinal hepato-diaphragmatic interposition, on the other hand, has previously been described but once, when it was recognized postmortem (2). In that case, a scout film made before the patient's death showed the condition but was misinterpreted as indicating a perforated viscus, whereas it actually represented an internal hernia through an opening in the falciform ligament, with obstruction of herniated small bowel loops interposed between liver and diaphragm. The rarity of reports of small intestinal hepato-diaphragmatic interposition is surprising when one considers the large number of reports of colonic interposition, particularly in view of the greater mobility of the small bowel. It seems possible that in many of the reported cases of colonic hepato-diaphragmatic interposition it was actually the small intestine that was interposed, for unless a barium enema study was performed, proof that the bowel was actually colon is lacking. The gas-distended ileum can simulate the large bowel (7), and what appear to be haustral indentations may actually be valvulae conniventes (see Fig. 1). As is the case with colonic hepato-diaphragmatic interposition, the diagnosis of small-intestinal interposition is essentially roentgenologic. Gas-filled loops of intestine between the diaphragm and the liver, demonstrated on either recumbent or upright abdominal films, or on a chest film, must be further studied with the barium enema. If it is the colon which is interposed the barium will enter the gas-filled loops. If, however, the entire colon is filled with barium and none is seen in the interposed loops, the diagnosis is interposition of the small intestine, as in the case to be reported here. The etiology of colonic interposition has been discussed in most of the papers on the subject. Bockus (1) lists the causes as submitted by Choussat and Choussat-Clausse: 1. Intestinal factors. (a) Megacolon or abnormal accumulation of gas in the intestinal tract, causing upward displacement of the diaphragm. (b) Abnormal mobility of the colon of congenital origin. 2. Diaphragmatic factors. (a) Abnormally high diaphragm due to thinning of musculature or to musculature degeneration. (b) Phrenic nerve injury or disease, with paralysis of the diaphragm. (c) Changes in intrathoracic pressure, as in tuberculosis, empyema, etc. 3. Hepatic factors. (a) Ptosis of the liver. (b) Small liver. (c) Relaxation of the suspensory ligament. (d) Fixation of the liver due to adhesions associated with traction produced by the gastrohepatic ligament or perigastritis. One or a combination of factors may be active in the production of the condition.

The Mucosal Pattern of the Terminal Ileum in Children

The mucosal pattern of the barium-filled normal terminal ileum under pressure in the adult appears as slender regular lines (Fig. 1) produced by the mucosal folds (Golden, 1). These folds may run either longitudinally or transversely. Referring to adults, Golden commented on the fact that the lymphoid cell collections in the mucous membrane do not produce a recognizable effect on the barium shadow. The mucosal pattern of the terminal ileum in children has been found to differ from that of adults. The purpose of this paper is to present evidence showing that this difference is produced by the relatively larger and more prominent normal lymphoid cell collections in children and that it is not abnormal. Anatomy The wall of the normal small intestine is composed of four coats, the serosa, tunica muscularis, submucosa, and mucosa (Fig. 2). The tunica muscularis consists of an outer longitudinal and inner circular layer. The submucosa consists of connective tissue, blood vessels, and lymph vessels. The mucosa is composed of the muscularis mucosa, the tunica propria, and the epithelium. The mucosal folds (valvulae con-niventes) are much higher and more numerous in the jejunum than in the ileum. These produce the mucosal pattern seen in barium studies. Small lymph nodes are present in the mucosa and submucosa; the apex of these solitary lymphatic nodes forms a domelike elevation of the surface of the mucous membrane. They are more numerous and higher in the ileum and may coalesce to form conglomerate groups of 20 to 30 nodules, commonly called Peyer's patches; these may be as much as 10 cm. in length (2). With increasing age, after puberty, the lymphoid tissue in the intestine, as well as that elsewhere in the body, is reduced in quantity (3). Roentgen Observations In routine gastro-intestinal studies on children under thirteen years of age, in the Babies Hospital (New York), it was noted that the terminal ileal pattern was different from that seen in adults. Small, rounded filling defects rather than slender, regular lines were found when pressure films were made. Since the patients in which these observations were made were examined because of abdominal complaints, it was decided to examine asymptomatic children as a further check on the roentgenographic appearance of the ileum. Studies were accordingly made on 14 hospitalized children, none of whom had abdominal complaints or was seriously ill. These patients were given barium sulfate in the morning on a fasting stomach. In 9 cases the barium was suspended in tap water; in the remaining 5 the suspension was made with normal saline, with distilled water, to rule out a possible response to an allergen. The patients were examined by fluoroscopy about two hours and a half later, and at intervals thereafter until the terminal ileum was filled. If the terminal ileum was not filled with barium after four hours, the patient was allowed to have food.

The Roentgen Diagnosis of Carcinoma of the Pancreas

The accuracy of the roentgenological method in the diagnosis of carcinoma of the gastro-intestinal tract is now fully recognized. Among the few abdominal viscera that do not yield to ready investigation by roentgen rays, the pancreas stands at the head of the list. There being no method available to make this organ sufficiently radiopaque to be visualized, recourse must be had to the indirect signs of pressure and encroachment on neighboring viscera for the demonstration of tumors arising from it. That such a method is considered subject to many inaccuracies and of questionable value, is attested by the few articles to be found in the literature, especially American, on this subject. Since the clinical diagnosis of tumors of the pancreas is often difficult, any aid which the roentgenologist can give is fully appreciated. A review of this problem together with the analysis of a group of twenty-three cases observed during the past seven years and the correlation of the roentgen and pathological findings will be presented. Review of Literature Dickson (7), in 1923, described the pressure deformities that might be produced on the stomach and duodenum by carcinoma of the pancreas. The only previous articles that he could find were by Hickey and by Herrenheiser of Vienna. In Dickson's opinion this lesion produced a displacement of the pylorus upwards and to the left, and of the descending duodenum to the right. The descending duodenum would show an irregular contour, would be fixed and might present areas of constriction and dilatation. While cysts might produce the same appearance, in his opinion the pressure deformity in this latter condition was smoother and more clear-cut. When the tumor occurred in the body of the gland, the transverse duodenum would show the effects of pressure with loss of the valvulae conniventes. With involvement of the tail the pressure deformity would occur on the lesser curvature of the stomach. Dickson believed that routine gastro-intestinal examination, following a barium meal, would give more information than could be obtained with pneumoperitoneum, and with less discomfort to the patient.

PRODUCTION OF PIGMENT IN THE CONJUNCTIVA

One of the most remarkable features in many cases of vitamin A deficiency in adults seen in the Orient is a peculiar brownish pigmentation of the conjunctiva. 1 The pigmentation is most marked in the conjunctiva of the lower fornix or of the inner canthus, i. e., the plica, where sometimes a deep brown color, similar to an intensive artificial argyrosis, may be seen. From the lower fornix the pigment extends to the joining lid and bulbar conjunctiva of the lower half of the conjunctival sac. The conjunctiva of the upper fornix and the upper lid may not become involved, and, even if they do, the pigmentation is always less than in the corresponding areas of the lower half of the conjunctival sac. Special mention should be made of the circular fold, the continuation of the plica semilunaris between the fornix and the bulbar conjunctiva. This