View source for Paper - Horizontal and vertical pancreas, in association with other developmental abnormalities (1922)

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| [[File:Mark_Hill.jpg|90px|left]] This historic 1922 paper by Bell describes abnormal development of the pancreas.

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=Horizontal and Vertical Pancreas, in Association with Other Developmental Abnormalities=

Howard H. Bell

Pathological Laboralory, Washington University School of Medicine, St. Louis, Missouri


Two Figures

==Introduction==

This type of abnormality in the development of the {{pancreas}} was described by Carnot.<ref>Carnot. Maladies des glands salivaires. Paris, 1908.</ref> The pancreas in his case possessed a head, a horizontal process 10 cm. long, resembling the body and tail of the normal pancreas, and a vertical process 12 cm. long extending downward from the head along the duodenum. Neve<ref>Neve. The Indian Medical Record, 1892, vol. 3, no. 3.</ref> mentioned extra tail lobes as an instance of reversion to a lower type. I have failed to find further reference in the Uterature to pancreas with horizontal and vertical processes, yet I have found two instances of this anomaly.


The first instance occurred in a well-nourished white male child, four months old. The cause of death was bronchopneumonia and extensive atelectasis.


The pancreas completely encircled the second part of the duodenum and possessed a horizontal and a vertical process. The band of pancreatic tissue encircling the duodenum was 10 mm. wide anteriorly, and 6 mm. wide posteriorly. The horizontal process resembled the normal pancreas. It measured 51 mm. long and 11 mm. in the other dimensions. Along the upper border near the duodenum was a rounded enlargement 1 1 mm. across. The vertical process descended along the mesial surface of the second part of the duodenum and passed anterior to the transverse part. This process measured 28 mm. long and 9 mm. in the other dimensions. The two processes and the annular part joined at the site occupied by the head of the normal pancreas. The annular part encircled the duodenum from behind forward and was in apposition with pancreatic tissue anteriorly, but not continuous with it. The duodenum was sUghtly constricted at this point.


The common bUe duct opened into the duodemmi with the pancreatic duct from the horizontal and vertical processes. The annular part possessed an individual duct opening into the duodenum slightly above and posterior to the ampulla of Vater.


Other developmental abnormalities were present. The interventricular septum of the heart was defective below the membranous part. This defect measured 21 mm. vertically, and 11 mm. horizontally. The foramen ovale and ductus Botalli were pervious, but the openings were very small. There was a slight umbihcal hernia and a small inguinal hernia on the right side. Meckel's diverticulima persisted and measured 5 cm. long.

The second anomaly occurred in association with anterior spina bifida and other abnormaUties which will be described elsewhere.

The infant was still-born at term. The stomach was greatly dilated. The small intestine joined the posterior wall of the stomach in the midhne of the body. It opened into the cavity of the stomach bj' a sht-Uke orifice guarded by a valve-hke fold. From the point where the intestine met the stomach to the site of its gastric orifice, it hes beneath the gastric peritoneiun (See Fig. 2). The gastric orifice of the intestine was 5.5 cm. from the pyloric end of the stomach. The pyloric end of the stomach had the form of a blind diverticulum into which the common bile duct opened. The horizontal and vertical pancreatic processes met upon this diverticulum. The diverticulum was about 1 cm. wide and 1.5 cm. long and ended in a blind rounded extremity.


The pancreas possessed a horizontal and a vertical process. The horizontal process extended across the anterior wall of the stomach and was loosely attached to it. It measured 65 mm. long, 9 mm. wide, and 4 mm. thick. The vertical process extended downward. Its lower extremity was shghtly enlarged and was turned abruptly backwards. The upper part of this process measured 34 nun. long, 9 mm. wide and 4 mm. anteroposteriorly. The lower part, which was enlarged and turned backwards, measured 12 nun. anteroposteriorly, 14 mm. vertically, and 5 mm. transversely. The horizontal and vertical processes were contiguous over the summit of the diverticulum. There were two papiUae with openings into the diverticulum, situated about 5 mm. apart. The duct from the vertical process led in conjunction with the common bile duct into the end of the diverticulvim. The duct from the horizontal process opened into the superior wall of the diverticulum.


The relation of the pancreatic processes and associated organs to the stomach is shown in fig. 1.

Many abnormahties were associated with the second specimen. The Uver was abnormal in shape. There was a funnelshaped diverticulmn from the posterior wall of the stomach below and posterior to the oesophageal opening, which was attached to the meninges through the anterior spina bifida. The relation of this opening to the stomach is shown in fig. 2. 

A summary of associated abnormalities is as follows:

Posterior spina bifida with myelocystomeningocele

Anterior spina bifida

Intraspinal pons, medulla and rudimentary cerebellum

Absence of tentorium cerebelh

Accessory superior longitudinal fissure in right hemisphere

Absence of islands of Reil

Absence of pineal body, aqueduct of Sj'h'ius and corpora quadrigemina

Abnormahty of heart

Defect in diaphragm on left side

Abnormahty of liver and stomach

Absence of greater omentimi

Bifurcated Meckel's diverticulum

Abnormal arrangement of small and large intestines

Undescended testicles

Tahpes varus. 

Two related cases described by Graefe<ref>The one described by Graefe possessed three pancreatic ducts, one of which opened into the stomach.</ref> and Vesalius<ref>Richeraud stated in his physiology that VesaUus described a case in which the ductus choledochus emptied into the stomach.</ref> were mentioned by Mondiere. <ref>Mondiere. Archiv. gen. de Med., 1836, 2d ser., T. 11.</ref>


Aberrant pancreatic tissue has occurred in the wall of the stomach in several instances.<ref>Opie, E. L. Disease of the pancreas. 1910. J. B. Lippincott Co., Philadelphia.</ref>

The human pancreas develops from one posterior and one anterior bud; occasionally there are two anterior buds which soon fuse to form one. The posterior and anterior processes grow together to form the mature pancreas.<ref>Keith. Human Embryology. 1913. Edward Arnold, London.</ref>


The shape of the pancreas varies in different species. The pancreas of the ox and {{sheep}} is irregularly quadrilateral in form.<ref>Sisson. Veterinary anatomy. 1910. W. B.SaundersCompany, Philadelphia.</ref> The pancreas of the horse is very irregular, although triangular in outline. The pancreas of the pig is elongated and situated transversely. The right portion has two lobes; the posterior lobe bends around the great mesenteric artery and the portal vein; the anterior one is pointed, extends downward and forward in the median plane and is attached in the portal fissure and to the duodenum. The left portion is prismatic and rests mainly on the left sac of the stomach, its left extremity being included between the left kidney and the dorsal end of the spleen. The pancreas of the dog is V-shaped, consisting of two long, narrow branches which meet at an acute angle. The right branch extends along the duodenum. The left branch is attached to the peritoneal surface of the stomach. In the cat the pancreas has two processes; one process extends along the duodenum and the other process extends along the stomach. The two processes are nearly at right angles to one another.<ref>Reighard and Jennings. Anatomy of the cat. 1910. Henry Holt & Co., New York.</ref> 

The first specimen resembles the pancreas of the dog and cat in that it has a horizontal and a vertical process, although it has in addition an annular process. The position of the pancreatic ducts in this specimen would indicate that the annular part developed from posterior budding and the horizontal and vertical processes from anterior budding.

The second specimen was associated with many unusual abnomiahties. The horizontal and vertical processes were in apposition on the summit of the gastric diverticulum^ although no fusion had taken place.

==Footnotes==
<references/>


==Plate 1==

Explanation Of Figures

1 Drawing of anterior view of liver, stomach, pancreas and spleen. The liver is raised, and the right end of the horizontal pancreas is elevated with forceps, to show the relation of the liver, the horizontal and vertical pancreas to the diverticulum of the stomach.

2 Drawing of posterior view of organs. The liver is tilted forward. Below and posterior to the oesophagus is shown the diverticulum which was attached to the cleft vertebrae. Below this diverticulum the small intestine passes obliquely through the wall of the stomach and opens into it.




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