920 THE USE OF INSULIN IN DIABETIC TREATMENT
Enemas aggregating 10 gm. sodium bicarbonate in one quart of saline
solution were partly retained. Consciousness was not recovered, and
death occurred at 3 P.M. Analyses of the blood plasma showed the
following.
Total
Sugar NaCI Urea Bicar- Ace-
Mg. Mg. Mg. bonate Nitro- tone
per per per Vol. prusside Mg.
100 cc. 100 cc. 100 cc. % per
100 cC.
10.00 a.m ................ 790 614 33 7.9 +-++ 74
11.45 a.m ................ 790 640 37 10.9 +++ .
1.15 p.m ............... 1072 610 48 23.3 ++++ 61
Abundance of carbohydrate was given in this case, in the belief that it
was relatively harmless and as a precaution against hypoglycemia from
the use of maximum insulin doses without immediate laboratory control.
Not only hyperglycemia but also acidosis persisted, and the coma ran an
unusually rapid fatal course both before and after the insulin administra-
tion, with no perceptible clinical change on account of the insulin. The
very low plasma bicarbonate, tympanites and anuria probably indicated a
hopeless case under any circumstances. The question of concealed infec-
tion must be considered more seriously than heretofore in such cases.
Case No. 1379. (Mild senile diabetes, with gangrene of toe. Failure
of insulin treatment due to inaccurate management.) Another patient
seen in consultation was an elderly woman with a typical history of
neglected mild diabetes, probably of very long duration. A small infec-
tion of the great toe had penetrated so as to involve the bones and
tendons, and the attending surgeon in three minor operations had re-
moved the entire toe. In addition, the second toe had recently suffered a
superficial burn from a hot water bottle. The reports showed continuous
mild glycosuria without acidosis on a liberal unweighed diet. The
wounds in the foot were sluggish, not seriously infected, but of the kind
which would ordinarily not heal on diet treatment. Favorable features
were the excellent general strength and the existence of good pulsation
in the arteries of the ankle and foot. Temperamentally, the patient and
her household seemed unsuited for rigid restriction of diet. An attempt
was therefore made to answer several questions: first, whether insulin
could accomplish healing of the wounds in such a case; second, whether
the patient might thus be spared undernutrition, the more generous diet
being perhaps one factor in the improved healing hoped for; and third,
whether these results could be attained in a case of mild diabetes without
weighing the diet.
For these purposes, a fixed plan of diet was mapped out, the quantities
of food being not weighed but estimated according to the size of the
various helpings, so as to insure against any great variations from day to
day. The surgeon in charge was supplied with insulin, which he was to