A Review of the Later Results of Insulin Treatment
BMJ (Clinical Research Edition)
In virgins the treatment mnay be effectuailly carried otLt bm ineanis of a rectal electrode, tlec procedure being similar * that utsed for heating the prostatO in men. In married womenl ani intrapelvic electrode, introduced inlto the vagina, isusd CASE T. In a girl, aged 16, the illness began at the end of 1923. The symptonms were then a general feeling of illniess and paini in the left hip. She was confined to bed for a short time, but was able to walk after this till just after Easter, 1924.
... l this time the knees became swollen and stiff, and when admitted to the. Vest Middlesex Hospital on May 1st she was unable to walk. Most of the joints were affected, the knees and wrists most severely. Whlen first seen the knees were flexed and could not be extended beyond a right angle, and the wrists were fixed in an extended position; the patient was thin and anaemic. Diathermy wyas applied by a rectal electrode on eight occasions, over a period fr om June 2nd to June 30th, 1924. At tlhe end of this time the knees could be completely extended and there was full range of movemenit of the wrists and fingers. There wk-3re nio pains anid she was beginning to walk. Synovial swelling of tlhe knees was still present. The quadriceps extensor muscles, especially tlle vastus internus, in both limbs were wasted. Massage and exercises were then commenced. On August 8th her general condition was good and she walked fairly well, but with an awkward gait. On November 3rd shc walked well. All joints were freely movable. There was slight swellinig of the yi-rists and knees. On November 27th the wrists and knees were s ff11 slightly swollen. She was tlhen doing physical exercises, incluiding skipping. At Clhristmas, 1925, complete functional restoration of all joints lbad t.aken place. She was fat and well, but still had an awkward gait. Menstruation had started at the age of 15, and bad been regular for six months. It then ceased for six months. At the end of this time it was re-established and remain-ed regular aft elrwards. " CASE II. A woman, aged 40, suffered from generalized arthritis resulting usi much suffering and ill health. She was so cripple.d as to be hardly able to walk with the aid of two sticks. She was thin aind had a sallow, unhealthy appearance. There was a marked tendency to growth of hair on the face. The wrists, knees, and ankles were swollen, painful, and tender. The right knee could be fully extended, but the left was flexed and could niot be extended and the patella was fixed. The left hip was flexed and fixed in that position. The illness had begun two and a lhalf years previously, and she had lhad a long course of treaLmoent, il;eIuding various forms of electrical treatment. During this the tonsils had been removed without effect. Treatment by diatlier my applied by a rectal electLrode was begun on Januarv 24tl, 1924. At the end of one month her general hiealth had much improved, and she had gai-ned 7 lb. in weight. The joints were more movable and almost free from pain. Treatment was theni left off till November, when she was found to have continued to improve during the interval. Her general lhealtlh was good and pain slight. The right knee was niornial, the left knee only slightly movable fr-om the fixed position of 120 degrees. The left hip was' still fixed. The treatment was renewed for one month and then left off till March, 1925. At this time her general health was good. There was no pain, but thie left knee remained flexed to 120 degrees and almost fxed. Durinig the last course of treatment she lhad menstiuated quiite normally, though the periods had been absent for four or five years previously. X-rav examination of the-left knee showed diminution of joint space, great lipping of upper and. lower margins of tqile pal ella with osteophytic formation" and extensive lipping of tibia and fibula at joint surfaces, with a fair amount of bone dest ruction. It is obvious that when the destruction and Inew bone formiation in the joint has advanced to such a confdition as existed in this case in th-e left knee, restoriatioen (if funcietion is outt of the questioni. The treatmenit resulted, hlowever in relief of paiin and in restoration of function in the other joints, and a retui-n to good general lhealth. It is only w%vh-en the arthritis is recent anid destruction and o0rganic changes of bone have not proceeded beyond a eertain point, thafit comnplete functional restoration im:ay be obtainedl, as ocetii-e(l in the first of these tw-o cases. Both of these patienits were vir-ginis, anid in neither w-as there any evidenco of infectioni of tlhe pelvic or11gans. In both there was evidence, apart from tho artlhritis, of .deficiency of ovarian interlnal secietion. In thle youniger of the tw-o patients it may be conisidered douibtfuil wlhether ;4)ie onset of puberty can be considered alnormal. There is,liowever, some evidence of deficiency of ovarian internial secretion in the interval of amenorrlhoea after the original onset of menstruatioln. In the older there was evidenice of (leficiency of ovarian internal secretion in the early cessationl of menstrulation and in the growth of hair oni the fasce?. It is noteworthy that in this case, as inl somze others .fa simlilar kindl treated in this w-ay, thle menses appeared after hlavinlg ceased for some y'ears. Corrobsoration of theb possibility of .stimullatinga thle formation of thle ovarian hormonle by heatinlg thle pelvic organls consists in the relief by tllis means of subjective symptoms and irregular haemorrhage dlue to the deficiency of ovarian internal secretion at the m-leniopauise. Several suceli resuilts have been obtained recently in this way in the electrical de)artment of St. Bartholomew's Hospital. The object of this paper is to puit forward tlhe conitention that therce exist cases of artlhritis occlrricg at eitlher enid of uninsti-tial life whiich ar-e inot due to inlfectioll, that in some of these, at all events, thle arthritis is ChIC to deficiencv of ovarianihornmone, an(d that in thcese the ar-liritis and accomnpaii-ying ill health are efficiently treated by heating'thie pelvic organs by meains of diatheriny. This is the first of a series of articles which we hop-e to publish on work carried oiit in the electrical departments of St. Bartholomew's and West Middilese Hospitols on the treatment of arthlitis and of gynaccolog,ical caseS. ASSISTANT PHYSICIAN TO THE GENERAL HOSPITAL, PHYSICIAN TO THE CHILDREN'S HOSPITAL, BIRMINGHAM. INthis paper I propose to review the results obtained by the insulin treatment of 100 cases of diabetes, in all of which the treatment began over a year ago, and in rather more thanl half of w-ihiclh it lhas continiued for nearly two years. Detailed con-sideration of ealrly progress under insulin treatment will be omitted-first, becauise tilis matter hias already been extensi-elyreported, and it is lnow well known that the vast majority of cases (lo very w--ell in tlhe in-itial period; and secondly, because tlie progress of patients after their retuirni to ordinary life is a matter of greater practical importance. The cases Ilave been taken in strict chronological order, and no case of any type that has received ilnsulini treatmenit for diabetes has beeni excluded, withl the exception of 15 patients it hias been impossible to trace. Of the 100 cases (44 in hospital, 56 in private) wlhose records are available, 25 are now dead (13 in lhospital practice, anid 12 in pri-ate); '15 deatlhs occurred durinig tlhe early period of treatliient, the remainider w-ithini a few nmonthis of beginlinig insullin. C('tses of Death. In no fewer than 17 of tlhe 25 cases it was clear that death resulted from some comnplication of the diabetes: 5 of them had severe tuberculosis (4 p-ulmoniary and 1 renal); gangrene was presenit in 4; 2 patients diedl of angina, anid 2 of heart failure witlhouit coma (both were over 70 wlhen insulin treatment was tried as a last resort); 3 cases had gross septic infectionis (1 mastoid disease, 1 pyoneplirosis, anid 1 iselio-rectal abscess); 1 case of renal infantilisro with slight diabetes died of utraemia; 7 cases died of coma that was apparently uncomplicated (there were post-inortein examinations in 3 onlyl). In 2 early cases -which oceurred when the supply of -ijisulin was limited the treatment was inadequate; 2 others were of the special tylw of coma to be described later; in 1 ease dleatlh followed rapidly from coma when inisulin was left off againist advice and an unirestricted (liet was takeni; the treatment of the 2 remaining cases was beguni wlhen the coma was far advanced. Oine patient died as the result of ilisulin treatment, a woman witih diabetes of moderate severity whlo was doing well wlhen she sucddenly became unconscious. The diagnosis of hypoglyeaemia was made atu once, and glucose was given intravenously. She appeared to rally slightly and a small injectioln of adrenalinee *As made intravenously to expedite recov-ery, but ventriculai fibrillatioln occurred and was immediately fatal. Death was probably due to the adrenaline, and this case demonstrates again the danger of the intraven-lous injection of this drug. An examination of these details shows tthat the 25 per cent. mortality recorded in this series gives too serious an * Rein,r tile substance of a post-gradtuate lectutre al the General Ilospital, Birmingham.