Systemic Embolism and Left Auricular Thrombosis in Relation to Mitral Valvotomy

repeatedly fulfilled Whipple's diagnostic criteria-(a) neurological disturbances occurring while fasting, (b) blood sugar below 50 mg. per 100 ml. , and (c) rapid relief on the administration of glucose. In all the previously reported cases of adenomatosis of the islets the condition has been discovered either at necropsy or after subtotal resection of the pancreas occasioned by relapse of symptoms following previous removal of single adenomata. Many authors, including Black et al. (1954) recently, stress the dark red or plum-coloured appearance of these neoplasms, and their firm consistency as compared with normal pancreatic tissue. Our case illustrates, however, that a state of adenomatosis may exist without any visible or palpable abnormality in the pancreas at operation. Indeed, though immediate examination of the excised body and tail revealed two small palpable nodules, neither of these in fact corresponded to any of the adenomata later demonstrated. ,(Such areas can often be felt in the normal pancreas, and may be due to localized increase in the interlobular fibrous tissue.) Though histological examination showed some of the tumours to be on the surface of the pancreas, a great number were deeply embedded in the glandular tissue, and are very unlikely ever to have been palpated. Again, the adenomata in this case showed no distinct colour which might separate them from normal pancreatic tissue. It is therefore evident that if the surgeon is convinced by the adequacy of the investigations that a patient's symptoms are due to hyperinsulinism, he should be prepared to perform a subtotal pancreatic resection even in the presonce of an apparently normal pancreas. As, normally, islet tissue is found in the greatest quantity in the tail and body of the pancreas, it would not be surprising if multicentric tumour development resulted in the adenomata being concentrated in these areas. Serial sections of the excised portion in the present case supported this view, and showed a diminishing number of tumours as the head was approached. This is, of course, of practical importance, as excision of the whole of the tail and the body will give the best chance of eradicating completely the tumour tissue. The process is simplified and its completeness ensured by removing the spleen at the same time. Despite these facts, the presence of some adenomata in the sections nearest the head makes it probable that there are further tumours in the head itself. The prognosis is therefore uncertain and further resection may be required. Another lesson to be learnt from this case is that focal neurological disturbances may result from hypoglycaemia. This was shown by focal pareses in the early history, focal twitchings in the later fits, and predominantly unilateral E.E.G. abnormality, corresponding to these manifestations. Black et al. (1954) reported a case developing a hemiplegia, and it seems that vascular insufficiency may be superimposed on the more diffuse pathological changes of hypoglycaemia described by Lawrence et al. (1952), and resembling the findings in cerebral anoxia. In obscure cases of epilepsy of late onset when investigations have failed to reveal a cerebral neoplasm, the diagnosis of cortical atrophy or cerebral arteriosclerosis is sometimes too easily accepted. Even if the fits are of focal type the possibility of hyperinsulinism should always be explored. A single normal early morning blood sugar should not, however, be considered to exclude the diagnosis, and complete starvation for at least twelve hours may be essential to produce the characteristic clinical picture and abnormally low blood sugars.