Ringworm of the Scalp

present attacks excluded the condition of cryptogenic hypoglycaemia. The occurrence of hypoglycaemia unresponsiveness in the insulin-tolerance test, with restoration of a normal response after removal of the islet-cell adenoma, indicates a causal relationship and affords confirmation of the suggestion of Fraser, Albright, and Smith (1941) that organic hyperinsulinism would be expected to produce hypoglycaemia unresponsiveness in the insulin-tolerance test. This case is typical of the cases of islet-cell adenomata already reported and illustrates many points. It shows the successful results of surgery in hyperinsulinism due to islet-cell adenomata. Medical treatment is indicated in cryptogenic hypoglycaemia but is dangerous in organic hyperinsulinism. A high-carbohydrate diet tends to fatten the patient and so makes for a poor operative risk later. Repeated prolonged hypoglycaemic attacks can cause permanent damage to the central nervous system. These tumours show a tendency to become malignant and there should be no delay in attempting operation. From this case it would appear that the coma, muscular twitches, and altered behaviour-equivalent to Himwich's (1944) cortical and subcortical phases of hypoglycaemiawere due to the low blood-sugar level. The symptoms such as lassitude, headache, and visual disturbances would seem to be due to adrenaline secretion reflexly induced by a sudden fall in the blood-sugar level. The small dose of adrenaline given during the glucose-tolerance test seemed to aggravate the symptoms of hypoglycaemia without altering the bloodsugar level. This case also showed that amphetamine sulphate could temporarily relieve the hypoglycaemic attacks, presumably by raising the blood-sugar level. A short post-operative period of hyperglyeaemia has been found in cases in which blood sugars have been estimated. This would appear to be due to the partial depression of the activity of the normal islets, while the requirements of the body were covered by the adenoma. The insulin resistance after operation may be due to persistence of a high level of the insulin antagonists, such as the glycotropic factor of the anterior pituitary. Finally, the case illustrates the great importance of accurate differential diagnosis in cases of spontaneous hypoglycaemia, the difficulty of attempting to diagnose hyperinsulinism by the glucose-tolerance test alone unless this is prolonged for several hours, and the value of the insulintolerance test in diagnosing organic hyperinsulinism.