Bronchial neoplasm with endocrine, metabolic, and neurological manifestations

History. B. M., a married woman aged 48, was admitted to the Royal Marsden Hospital on March 3, 1965. In 1945, following her only pregnancy, she had postpartum depression. Since the middle of 1963 she had again suffered from depression and anxiety. In August 1964, she had had an episode of chest pain, hemoptysis, cough, and malaise which was thought to be due to pneumonia, and in October she noticed deterioration in her eyesight. Her menstruation had been irregular for the past year, and her last period began Jan. 20, 1965. In January 1965, she had an attack of pneumonia and was admitted to another hospital, where she gave a week‘s history of swelling of the face and legs associated with insidious onset of dyspnea on exertion. Examination. She had the appearance of a patient with Cushing’s syndrome, with bilateral pitting edema of the lower limbs, and her blood pressure was 180/100. There were no abnormal signs in the chest but she had vague epigastric tenderness. The urine examination was normal. Investigations. The chest X-ray showed a mass at the right hilum. Bronchoscopy showed the carina widened and rigid with slight deformity and an irregular area in the medial border of the right lower lobe bronchus. Biopsy revealed oat-cell carcinoma. The serum electrolytes were sodium, 140 mEq. per liter; potassium, 3.2 mEq. per liter; chloride, 99 mEq. per liter; calcium, 11 mg. per 100 ml.; and inorganic phosphate, 3.8 mg. per 100 ml. The glucose tolerance test showed a fasting level of 108 mg. per 100 ml. and then 225, 245, 203, 158, and 115 mg. per 100 ml., respectively, after thirty, sixty, ninety, one hundred twenty, and one hundred fifty minutes. There was moderate glycosuria during the test. The mean twenty-four-hour excretion of urinary 17-oxogenic steroids, based on three specimens, was 24 mg. The plasma cortisol was 16.6 pg. per 100 ml. on admission and rose to 50 pg. per 100 ml. four weeks later. Progress. She was given metyrapone ditartrate (Metopiron&), 750 mg. every eight hours for ten days with no apparent improvement, and on Feb. 24, 1965, she had an intravenous injection of 0.5 mg. of vincaleukoblastine. On March 3, 1965, she was transferred to the Royal Marsden Hospital. She was euphoric but cooperative, alert, and oriented and was able to give a full and detailed history, though she had no specific complaints. Examination. The patient’s skin was dry and hyperpigmented with a few purple striae on her face, which was round. No evidence of edema was seen. Heart and lungs were normal, and her blood pressure was 180/100. No abnormal physical signs were found in the nervous system. Over the next two days she had periods of euphoria alternating with depression, but her memory for recent events was good. Investigations. The hemoglobin was 77% with slight hypochromia, and the white blood cell count was 14,900 ( polymorphs 81%, lymphocytes 14%, monocytes 4%, plasma cells 0.5%, metamyelocytes 0.5%). Blood urea nitrogen was 15 mg. per 100