14) Post hypoglycemic Encephalopathy, case reports, by George M Jones, M.D. American Journal of Medical Services, 1947, 213.

'The Clinical entity post hypoglycaemic encephalopathy, has been previously reported under headings of synonyms such as fatal hypoglycaemia, mental deterioration associated with convulsions and hypoglycaemia, cerebral damage from insulin shock, irreversible or hypoglycaemic insulin coma, fatal hyper insulinism with cerebral lesions due to pancreatic adenoma, and post hypoglycaemic coma or syndrome, and psychiatric complications of hypoglycaemia in children. Even before the introduction of insulin, Joslin recognised that hypoglycaemia was a very serious factor in the treatment of diabetes.'

In 1932' Terplan reported the case of a 16 year old boy who did not regain consciousness for 3 days after insulin shock, the blood sugar levels being normal for these 3 days. Post-mortem examination showed extreme oedema of the brain and destruction of ganglion cells.' Wilder wrote:' a feature of this type of coma (hypoglycaemia) that is very characteristic is its rapid termination when glucose is administered.'

Case 1 - 26 year old white man, diabetic for 4 years, September 8 1943, found unconscious, perspiring profusely and unresponsive, transferred to hospital. 'The patient became quite unruly and violent, struggling constantly, having to be restrained, and pulled out the intravenous needle after only 300cc of 5% glucose had been administered.' There was no change in the clinical course during the interval except that the patient screamed irrationally at times.' 'Thereafter the Patient improved and apparently had an uneventful course after proper regulation of his diabetes.'

Case 2 - 55 year old white male, diabetic since 1938, was admitted to st Paul's Hospital in diabetic coma on February 13th 1945 at 12 noon having been found unresponsive at 10.00 am, but was alright at 7am. 10% glucose solution was started intravenously immediately upon his arrival and was continued until the patient had received 4000cc by 10.45pm. The Patient remained semi comatose on March 1st until 9.00pm at which time he appeared very restless, got out of bed, struggled with the nurses, and had alternating intervals of crying out irrationally and of being quiet. The patient remained about the same until the 16th March when he became weaker, his temperature began rising, and signs of pneumonia appeared in the lungs. He died on March 18th at 8.20pm.

Case 3 - 7 year old white male, diabetic since January 1943, admitted to Baylor University hospital at 4.30pm on September 27 1945 following convulsions. As the patient continued to have convulsions and was comatose it was decided to bring the child to Dallas. The patient was admitted to hospital upon arrival.' The patient was given 70cc of 50% glucose and 1000cc of 10% glucose intravenously. At 6.00pm on September 28th, respirations ceased permanently.' The patient died.

Clinically cases of post hypoglycaemia encephalopathy have been reported in every age group, as frequent in children as in adults.

'Darrow had 2 cases of convulsions and mental deficiency in children following hypoglycaemia.' Another similar case with coma for 17 days terminating in death reported by Lawrence et al.

It is recommended that the term post hypoglycaemic encephalopathy be used for this very definite clinical entity. Members of the medical profession should be aware of this very serious complication of hypoglycaemia and combat any prolonged low blood glucose level vigorously.

15) Patients who carefully Manage Diabetes May Face Hidden Risks, By James s Hirsch, Wall Street Journal 29.6.1996. This describes a 26 year old insulin dependent diabetic nurse, two months pregnant, who following diabetic coma, lost control of her car which battered off the road and crashed into a tree, killing her. Authorities estimate she was travelling at 73 miles per hour and there was no skid marks. She passed out and her foot hit the accelerator. Research studies estimate that between 4% and 13% of the insulin dependent diabetic patients who die each year perish in hypoglycaemia related accidents.

16) Human Insulin - A Decade of Experience and Future Developments - Diabetes Care Dec 1993

17) Report to BDA Low Task Force - 1992

18) Human Insulin Advice - Forest & Evans 1992

19) Hypoglycaemia Unawareness in Diabetics Transferred from Beef / Porcine Insulin to Human Insulin - A. Teuscher; W D Berger, The Lancet August 15 1987

20) Human insulin and unawareness of hypoglycaemia: need for a large randomised trial - Egger, Smith, Teuscher, BMJ August 1992

21) The Diabetes Handbook - Day, BDA 1986

22) DCCT Diabetes Control and Complications Trial - 1993

23) Bellagio Report - 1996

24) Diabetes & cognitive function: the evidence so far - A British Diabetic Association Report November 1996

25) Hypoglycaemia in insulin requiring diabetes - A patient and carer perspective - IDDT 1997

26) Cochrane Review - 'Human' insulin versus animal insulin in people with diabetes mellitus - Richter, Neises 2002

27) INSULIN - A Voice for Choice by Professor Arthur Teuscher, Karger 2007

28) 30 YEARS OF SYNTHETIC INSULIN, ARE PEOPLE WITH DIABETES GETTING THE BEST DEAL? A report of patient's concerns IDDT 2007