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PANCREATIC NEOPLASMS IN DIABETICS
542
surrounding renal injury in abruptio virtually unique in obstetrics, a solution to this of maternal mortality may be delayed.
that the circumstances
placenta: major
are
cause
National Maternity Hospital,
Dublin,
2.
KIERAN O’DRISCOLL FRANCIS GEOGHEGAN.
HOW MANY CELL-GENERATIONS? SIR,-Iread Dr. Kay’s hypothesis (Aug. 28) with interest, but I believe that he complicates his problem by trying to find a single law to govern all cellular divisions. In fact it is very much simpler to accept that, during differentiation, metazoan cells are forced into one of four patterns of behaviour. The first pattern is that of the prolific cell in which division produces sister cells which are similar; so that multiplication is
geometric.
phosphatase 79 King-Armstrong units; serumglutamic-pyruvic-transaminase 106 units per 100 ml. ; bilirubinalkaline
uria but
no
urobilinuria; normal barium meal; and,
on
chole-
cystography, a non-filling gallbladder. Laparotomy showed a large carcinoma of the head of the pancreas and a grossly distended gallbladder, and a choledochojejunostomy was performed. In all 4 of Dr. Cohen’s cases physical signs associated with pancreatic neoplasms were present which indicated late disease: in 3 there were metastases, and in his 4th case, as in the one we have described, there was local infiltration. This does not support Dr. Cohen’s contention that the condition is early when diagnosed. We, however, believe that it may be possible to make an early diagnosis if investigations are urgently done in a diabetic who has persistent abdominal pain, unaccountable weight loss, or sudden deterioration of diabetic control. If the suspicion is strong, a laparotomy may be indicated, even with
The second pattern is that of the stem cell in which division results in unlike sister cells--one sister being a stem cell similar negative investigations. to the parent, while the other is an end cell or its precursor. V. K. G. PILLAY Ashford Hospital, R. I. GLEADLE. Multiplication in the stem cells maintains but does not increase Middlesex. the stem-cell population. The third pattern is that of the end cell mentioned above. This cell is itself a neuter, but its population can be maintained HÆMOTHORAX AND OSTEOMALACIA or increased by stem-cell division. SIR,-Osteomalacia is rarely a killing disease, because in The fourth pattern is the true neuter, which differentiates at its complications are those of slowly developing bony general the appropriate stage of morphogenesis, and cannot thereafter In elderly people whose bones are brittle, fractures deformity. either divide or have its population augmented. Quite possibly rather than deformities occur. In the following case osteothe only true neuter cell is the neuron cell. malacia led to multiple rib fractures with h2emothorax and, The interesting problem of biology today is to find the laws eventually, death. which govern the interrelations of these four kinds of cell. I A 75-year-old woman had a previous history of a stroke submit that if we make one not unreasonable suppositionfollowed by thrombophlebitis in her leg, at which time she namely, that all cells are at the same time essential suppliers and was noted to have hypertension with heart-disease and leftinsatiable consumers-we can quite easily cover the whole bundle-branch block. Two years later retinoscopy, carried problem with the three perfectly ordinary laws of ecology. out because of decreasing visual acuity, revealed severe Paraphrasing these laws we could express them thus: bilateral arteriosclerotic changes and exudates. 1. A prolific population multiplies until it is restrained by On Jan. 25, 1965,I saw the patient at her home because of shortage of supplies, as in liver regeneration, where loss of difficulty in walking. She lived alone and wasI increasing some cells allows the remainder to multiply. having ’Theominal’ tablets 1 twice daily, ’Stemetil 2. Competing populations restrain and regulate each other, tablets 1 twice daily,Bufferin ’ as necessary, and ’Sodium as in red blood-cell regulation, where a loss of end cells Amytal ’ gr. 3 at night. She was pale, filthy, cocooned in allows the stem. cells to multiply. clothes, and obviously neglected. She complained of a 3. The size of a permissive population regulates and painful left shoulder and, as far as I was able to examine her, limits the size of any populations which are dependent on it, I found her to have left hemiplegia, a stiff left shoulder, and as shown by the limited growth-potential of metazoa in an old fracture of her left ankle. Her pulse was irregular contrast to the unlimited growth and lifespan of parazoa. owing to extrasystoles. She had slight oedema of the ankles, The parazoa have no neuter cells. and cyanosis of the lips and hands, and could walk with the Obviously I have oversimplified, and I hope that my aid of a stick. I arranged to have her admitted to hospital. ecologist colleagues will pardon me, but I maintain that the On the day she was to be admitted (Jan. 26) the police were problem is not nearly so complex as we believe. called because she was lying moaning behind the door. MICHAEL FROST. Colchester, Essex. On admission the previous findings were confirmed, but she also complained of pain at the base of her left lung, and wheeziness. There was a little dullness at the base of the PANCREATIC NEOPLASMS IN DIABETICS left lung posteriorly, and in both lungs a few rhonchi were SIR,-We read with interest the article by Dr. Cohen heard. She was cyanosed and had sacral oedema. Her pulse (Aug. 7). We here report another case illustrating the syndrome was irregular. Serum-calcium was 7-5 mg. per 100 ml., of pancreatic neoplasms in diabetics. inorganic phosphate 3-1 mg. per 100 ml., alkaline phosA 66-year-old woman presented in July, 1960, with a history phatase 30 6 units, and total protein 6-5, indicating grade-n of about 2 stones (13 kg.) loss of weight in 2 years. She had had biochemical osteomalacia. X-ray of chest on Jan. 29 showed 8 children, the last being a stillbirth; all were over 9 lb. (4 kg.) extensive fractures of the left side involving the 3rd to 11th ribs at birth. There was no family history of diabetes. Her own inclusive and some callus at the fractures of the 9th to llth ribs. There was also a considerable amount of fluid in the weight was 11 st. 2 lb. (71 kg.); she was found to be a diabetic, and was satisfactorily controlled on a 1000-calorie diet, but her left side of the chest, with some fluid extending over the remained weight fairly steady. apex of the lung. Electrocardiography on Jan. 26 showed The patient again presented on June 25, 1965, complaining multifocal supraventricular and nodal paroxysmal tachycardia. of over a stone (6-6 kg.) loss of weight in 2 months, and The left basal dullness increased, and on Jan. 30 2 pints of abdominal pain. She had a palpable tender liver; a random blood was aspirated from the left side of her chest. Despite blood-sugar was 325 mg. per 100 ml., but there was no acetonthis, the hxmothorax continued’to increase, although the uria. By a month later she had lost a further half-stone, patient improved symptomatically. On Jan. 30 she was noted to and insulin was acetonuria was have paradoxical movements of the left upper chest owing to a soluble present, pronounced bucket-handle action of the ribs, associated with anterior and given to control the diabetes. She was jaundiced, the liver was 3 fingerbreadths below the right costal margin, and the spleen posterior rib fractures. Her chest was strapped over the mobile portion, and a surgical opinion was sought. On was also palpable. revealed: serum-bilirubin 7-7 Feb. 2, the thoracic surgeon stated that there was nothing 100 ml.; Investigations mg. per
surrounding renal injury in abruptio virtually unique in obstetrics, a solution to this of maternal mortality may be delayed.
that the circumstances
placenta: major
are
cause
National Maternity Hospital,
Dublin,
2.
KIERAN O’DRISCOLL FRANCIS GEOGHEGAN.
HOW MANY CELL-GENERATIONS? SIR,-Iread Dr. Kay’s hypothesis (Aug. 28) with interest, but I believe that he complicates his problem by trying to find a single law to govern all cellular divisions. In fact it is very much simpler to accept that, during differentiation, metazoan cells are forced into one of four patterns of behaviour. The first pattern is that of the prolific cell in which division produces sister cells which are similar; so that multiplication is
geometric.
phosphatase 79 King-Armstrong units; serumglutamic-pyruvic-transaminase 106 units per 100 ml. ; bilirubinalkaline
uria but
no
urobilinuria; normal barium meal; and,
on
chole-
cystography, a non-filling gallbladder. Laparotomy showed a large carcinoma of the head of the pancreas and a grossly distended gallbladder, and a choledochojejunostomy was performed. In all 4 of Dr. Cohen’s cases physical signs associated with pancreatic neoplasms were present which indicated late disease: in 3 there were metastases, and in his 4th case, as in the one we have described, there was local infiltration. This does not support Dr. Cohen’s contention that the condition is early when diagnosed. We, however, believe that it may be possible to make an early diagnosis if investigations are urgently done in a diabetic who has persistent abdominal pain, unaccountable weight loss, or sudden deterioration of diabetic control. If the suspicion is strong, a laparotomy may be indicated, even with
The second pattern is that of the stem cell in which division results in unlike sister cells--one sister being a stem cell similar negative investigations. to the parent, while the other is an end cell or its precursor. V. K. G. PILLAY Ashford Hospital, R. I. GLEADLE. Multiplication in the stem cells maintains but does not increase Middlesex. the stem-cell population. The third pattern is that of the end cell mentioned above. This cell is itself a neuter, but its population can be maintained HÆMOTHORAX AND OSTEOMALACIA or increased by stem-cell division. SIR,-Osteomalacia is rarely a killing disease, because in The fourth pattern is the true neuter, which differentiates at its complications are those of slowly developing bony general the appropriate stage of morphogenesis, and cannot thereafter In elderly people whose bones are brittle, fractures deformity. either divide or have its population augmented. Quite possibly rather than deformities occur. In the following case osteothe only true neuter cell is the neuron cell. malacia led to multiple rib fractures with h2emothorax and, The interesting problem of biology today is to find the laws eventually, death. which govern the interrelations of these four kinds of cell. I A 75-year-old woman had a previous history of a stroke submit that if we make one not unreasonable suppositionfollowed by thrombophlebitis in her leg, at which time she namely, that all cells are at the same time essential suppliers and was noted to have hypertension with heart-disease and leftinsatiable consumers-we can quite easily cover the whole bundle-branch block. Two years later retinoscopy, carried problem with the three perfectly ordinary laws of ecology. out because of decreasing visual acuity, revealed severe Paraphrasing these laws we could express them thus: bilateral arteriosclerotic changes and exudates. 1. A prolific population multiplies until it is restrained by On Jan. 25, 1965,I saw the patient at her home because of shortage of supplies, as in liver regeneration, where loss of difficulty in walking. She lived alone and wasI increasing some cells allows the remainder to multiply. having ’Theominal’ tablets 1 twice daily, ’Stemetil 2. Competing populations restrain and regulate each other, tablets 1 twice daily,Bufferin ’ as necessary, and ’Sodium as in red blood-cell regulation, where a loss of end cells Amytal ’ gr. 3 at night. She was pale, filthy, cocooned in allows the stem. cells to multiply. clothes, and obviously neglected. She complained of a 3. The size of a permissive population regulates and painful left shoulder and, as far as I was able to examine her, limits the size of any populations which are dependent on it, I found her to have left hemiplegia, a stiff left shoulder, and as shown by the limited growth-potential of metazoa in an old fracture of her left ankle. Her pulse was irregular contrast to the unlimited growth and lifespan of parazoa. owing to extrasystoles. She had slight oedema of the ankles, The parazoa have no neuter cells. and cyanosis of the lips and hands, and could walk with the Obviously I have oversimplified, and I hope that my aid of a stick. I arranged to have her admitted to hospital. ecologist colleagues will pardon me, but I maintain that the On the day she was to be admitted (Jan. 26) the police were problem is not nearly so complex as we believe. called because she was lying moaning behind the door. MICHAEL FROST. Colchester, Essex. On admission the previous findings were confirmed, but she also complained of pain at the base of her left lung, and wheeziness. There was a little dullness at the base of the PANCREATIC NEOPLASMS IN DIABETICS left lung posteriorly, and in both lungs a few rhonchi were SIR,-We read with interest the article by Dr. Cohen heard. She was cyanosed and had sacral oedema. Her pulse (Aug. 7). We here report another case illustrating the syndrome was irregular. Serum-calcium was 7-5 mg. per 100 ml., of pancreatic neoplasms in diabetics. inorganic phosphate 3-1 mg. per 100 ml., alkaline phosA 66-year-old woman presented in July, 1960, with a history phatase 30 6 units, and total protein 6-5, indicating grade-n of about 2 stones (13 kg.) loss of weight in 2 years. She had had biochemical osteomalacia. X-ray of chest on Jan. 29 showed 8 children, the last being a stillbirth; all were over 9 lb. (4 kg.) extensive fractures of the left side involving the 3rd to 11th ribs at birth. There was no family history of diabetes. Her own inclusive and some callus at the fractures of the 9th to llth ribs. There was also a considerable amount of fluid in the weight was 11 st. 2 lb. (71 kg.); she was found to be a diabetic, and was satisfactorily controlled on a 1000-calorie diet, but her left side of the chest, with some fluid extending over the remained weight fairly steady. apex of the lung. Electrocardiography on Jan. 26 showed The patient again presented on June 25, 1965, complaining multifocal supraventricular and nodal paroxysmal tachycardia. of over a stone (6-6 kg.) loss of weight in 2 months, and The left basal dullness increased, and on Jan. 30 2 pints of abdominal pain. She had a palpable tender liver; a random blood was aspirated from the left side of her chest. Despite blood-sugar was 325 mg. per 100 ml., but there was no acetonthis, the hxmothorax continued’to increase, although the uria. By a month later she had lost a further half-stone, patient improved symptomatically. On Jan. 30 she was noted to and insulin was acetonuria was have paradoxical movements of the left upper chest owing to a soluble present, pronounced bucket-handle action of the ribs, associated with anterior and given to control the diabetes. She was jaundiced, the liver was 3 fingerbreadths below the right costal margin, and the spleen posterior rib fractures. Her chest was strapped over the mobile portion, and a surgical opinion was sought. On was also palpable. revealed: serum-bilirubin 7-7 Feb. 2, the thoracic surgeon stated that there was nothing 100 ml.; Investigations mg. per