Osteomalacia is a bone disease more commonly seen and with greater clinical 'implications in North China than elsewhere (1, 2, 3). The principal cause of the skeletal demineralization resides in vitamin D deficiency, a combination of its lack in the diet and exclusion of sunlight. By reason of such deficiency, calcium given by mouth fails to be absorbed. Poor intestinal absorption rather than excessive elimination is incriminated because it has been demonstrated by the studies of Hannon et al. (4) that the endogenous calcium metabolism in patients with osteomalacia on low intake is within normal limits and that calcium administered parenterally is largely retained. Under such circumstances while the endogenous destructive activity in the bones may not be excessive, the reparative process is very much interfered with through defective intestinal absorption so that skeletal decalcification inevitably ensues. The limited intake of calcium in common Chinese dietaries (5), and periods of mineral stress incident to pregnancy and lactation are some of the contributing factors that enter into the pathogenesis of osteomalacia.Studies of the effect of vitamin D in the treatment of osteomalacia (4, 6) demonstrate the remarkable'conserving action of vitamin D on calcium and phosphorus metabolism. As a result of its administration, intestinal absorption is promoted and endogenous elimination is decreased so that large quantities of calcium and phosphorus are available for deposition in the bones. The actual amount of calcium and phosphorus retained depends upon the level and ratio of intake of these elements. It has been shown in two patients with osteomalacia undergoing reparation initiated by vitamin D (7) that calcium retention varied directly with calcium intake while phosphorus retention was limited by both calcium and phosphorus intake. Fecal calcium likewise varied directly with calcium intake while fecal phosphorus was parallel with both calcium and phosphorus intake. When calcium supply is limited in relation to phosphorus (low Ca: P ratio) practically all the calcium absorbed is deposited, none appearing in the urine. On the other hand, when phosphorus supply is short compared with calcium (high Ca: P ratio), all the available phosphorus is retained and urinary phosphorus vanishes. Conservation of excretion through the urinary tract and efficient absorption through the intestinal canal account for the markedly positive balances in osteomalacia when reparation is brought about under the influence of vitamin D.Similar observations on the effects of variations of the levels and ratios of calcium to phosphorus intake on their serum levels, paths of excretion and balances have been made on another patient with healing osteomalacia. But in contrast to the previous patients who received vitamin D only prior to the observations, the present subject was given vitamin D throughout the entire study so as to obviate any uncertainty in ascribing the metabolic results obtained to vitamin D action. Moreover, attempt was made in ...

Shortly after Banting and Best's discovery of insulin (1), Harris (10) in 1924, on the basis of cases of hypoglycemia with symptoms similar to those of insulin shock and relievable by feeding, postulated the occurrence of spontaneous " hyperinsulinism " as opposed to the " hypoinsulinism " of diabetes. The first verification of this hypothesis appeared in 1927 in a report by Wilder, Allan, Power and Robertson (26) of a case of intractable hypoglycemia. The patient, on exploration, showed carcinoma of the islet tissue of the pancreas with metastasis to the liver. Insulin was demonstrated in the hepatic metastases. Two years later Howland, Campbell, Maltby and Robinson (12) reported the first case of pancreatic islet adenoma which was diagnosed preoperatively, identified at operation and excised with favorable result.In the past few years the literature on hyperinsulinism has grown tremendously. A review by Whipple and Frantz (25) of all the published cases of hyperinsulinism and islet tumor has appeared very recently. According to their analysis of the 157 cases reported, 75 cases of hypoglycemia were ascribed to hyperinsulinism without verification at operation or autopsy. Of the 82 remaining cases in which the pancreas was examined, normal tissue was recorded in 13 instances, hypertrophy of the islands in 4 instances and chronic inflammatory change in 3, leaving 62 instances in which a tumor of the pancreatic islands was found. Analyzing further the 62 cases of tumor, exactly 50 per cent were incidental necropsy findings without recorded hypoglycemia. The group of 31 cases of tumor associated with hypoglycemia consists of 10 discovered at autopsy and 21 at operation. Among the last 21 cases, 4 were instances of carcinoma in which death occurred shortly after operation in 2 instances. In February 1934 generalized clonic convulsions were first noticed, accompanied by coma. Subsequently similar seizures recurred almost every night, usually between 2 and 4 a.m. According to the description given by his wife, the onset of the seizures was marked by a cessation of the snoring which occurred regularly during sleep and the opening of his eyes accompanied by staring and grimacing. Twitching movements first involved the lower limbs and then the upper. In the beginning the movements were slight and then more violent.Occasionally the tongue was bitten. Each series of con-249

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