Although high and low blood sugar levels are the most obvious complications of diabetes, they are not the most common. Today, the most common reason for hospitalization of diabetic patients is, surprisingly, foot injuries. Elevated blood glucose levels cause damage to nerves and blood vessels, particularly in the feet. The nerve damage prevents the pain from being transmitted to the brain, and the blood vessel damage slows the healing process. Without proper care, minor cuts to the feet can fester, and eventually lead to amputation.
Foot problems are not unique to the modern era. In late 1926, a sixty-one year old woman cut her foot while trying to remove a callus from the sole of her right foot. The injury was minor; just a bit of blood was drawn. Over the next few weeks, her foot began to swell and hurt. The pain and swelling soon encompassed her whole foot and the lower part of her leg.
She let the wound fester, perhaps hoping it would cure itself. But, it didn’t. Three months later, she appeared at the Royal Victoria Hospital in Montreal. The examining physician, a Dr. Edward Mason, found an open wound, or an ulcer, on the bottom of her foot. The wound was obviously infected; it was filled with pus. She also had lymphangitis, an infection of the lympthatic channel, extending up her right leg. On the positive side, the doctor could feel a pulse in her foot, indicating blood flow to the extremity.
Dr Mason drained the wound and performed some routine tests. He noted a high level of glucose in her urine, suggesting she had diabetes, a condition she was unaware of. He prescribed insulin (initially 20 units per day) and recommended she follow a strict diet to control her blood glucose levels.
The woman remained at Royal Victoria Hospital for about ten weeks, being discharged in April of 1927. At the time of her discharge, her foot had healed and she had no detectable glucose in her urine.
After returning home, she followed her diet and took her insulin each day. Sometime in August, four months later, she stopped taking insulin; she could not afford it anymore. Skipping the insulin probably led to no immediate health problems and justified her skipping it.
Four months after stopping the insulin, in late December, she developed another problem. This time she started feeling a prickling sensation in the sole of her left foot. At first, there was no visible problems with the foot. But shortly after the prickling started, an open sore developed on the bottom of her foot and one of her toes became discolored. She waited another month before returning to Royal Victoria Hospital.
Dr Mason examined her again on January 22, 1928. He found her left foot completely swollen, a large open wound on the bottom across the center of the foot, and a black patch that completely encompassed her second toe extending an inch down into the foot. He consulted with a surgeon, who recommended immediate amputation of the foot. Dr Mason could not feel any pulse in the left foot, indicating poor blood circulation. Laboratory tests revealed highly elevated levels of glucose in her urine, and an x-ray showed that the arteries in her left foot had extensive calcification, atherosclerosis.
He once again drained and cleaned the wound, then returned the woman to insulin. The patient’s diabetes was under control within two days. Her foot gradually improved. The wound on the bottom of her foot was replaced by healthy tissue, but the second toe dropped off.