PART OF THE Illumination ISSUE

‘Reports about insulin from Toronto were greeted with scepticism, especially in Europe’

In this thought-provoking excerpt Tattersall, a leading medical authority on diabetes, traces the evolution of the disease – named ‘the pissing evil’ in the 16OOs by the Royal Physician to King Charles I – in the twentieth century.

Extract from The Pissing Evil: A Comprehensive History of Diabetes Mellitus
By Robert Tattersall
Published by Swan & Horne

Given the thirty-year history of false dawns since 1889, it is not surprising that the reports about insulin from Toronto were greeted with scepticism, especially in Europe. It is said that Naunyn wrote to Minkowski telling him not to believe a word of it as it was another case of American bluff! However the imprimatur of the North American scientific community was given at a meeting of the Association of American Physicians on 3 May 1922, when Macleod presented the clinical results. No physician present seemed to doubt them and Rollin Woodyatt moved that the association give a standing vote of appreciation to Macleod and his associates. Joslin could not remember such an action in the twenty years he had been involved with the society. Insulin was first supplied to American physicians in August 1922 and their experiences were published in a special edition of Allen’s Journal of Metabolic Research; this did not come out until 1923. The journal contained ten papers and was 438 pages long.

It is a truism that a picture is worth a thousand words. The most impressive papers at that time were those by Rawle Geyelin and Kansas professor of medicine, Ralph Major; both were illustrated with before and after photographs of the children they had treated. The main aim was to fatten up these extremely emaciated children, so they were deliberately given two or three times more carbohydrate than they received previously.

One case in Geyelin’s paper was a 15-year-old girl who had developed symptomatic diabetes in 1918 and was treated with the standard regimen including occasional fasting days. In July 1921 she was admitted to hospital because she still had glycosuria on as little as 20 g of carbohydrate daily. She was eventually discharged with her carbohydrate and fat allowances halved. Unsurprisingly, she deteriorated over the next year and was so weak she could not go to school. In July 1922 she was admitted again, this time for acidosis, with a blood sugar of 428 mg/dL (23.8 mmol/L) and weighing just 46.75 lb (21 kg). She was discharged on an exceptionally restricted diet – 6 g of carbohydrate, 25 g of protein and 30 g of fat per day – on which she still had continuous glycosuria. In September 1922, on three control days before insulin was started she excreted 44 g of sugar per day, weighed 48 lb, and had generalised oedema. Over the next six months, while on insulin, she grew by 3.2 cm, her weight increased from 48 to 57 lb, and her daily carbohydrate was increased from 10 to 55 gm.

Another case described a 10-year-old boy with diabetes for four and a half years who, when admitted for insulin in November 1922, was so weak he could not lift his head from the pillow without help. Emaciation was extreme and he weighed only 27 lb (14.6 kg). Over the next three months he grew by 2 cm and his weight increased to 48 lb. On a diet of 80 g of carbohydrate a day he took 35 units of insulin per day. What is interesting from the chart in the paper is that the lowest blood sugar of 240 mg/dL (13.3 mmol/L) was recorded before he started insulin.

The most famous before-and-after pictures are those of a patient of Major – Billy Leroy. In the first picture, the three-year-old Billy had had diabetes for two years and weighed only 6.8 kg. In the second picture, taken after three months, his weight had increased to 13.6 kg and he was aglycosuric on a daily regimen of 55 g of carbohydrate and 25 units of insulin. These pictures were not representative of all patients who survived the Allen starvation regimen because, as Chris Feudtner pointed out, hardly any young patients starved to the degree of those shown in the dramatic pictures; they had lost 30% or more of their body weight, but 10% was more typical.

Joslin’s first patient to be treated with insulin (also reported in the Journal of the American Medical Association in June 1923) was Miss Mudge, aged 42, who had had diabetes for five years during which time her weight had fallen from 72 kg to 33 kg. She could not be kept sugar free on any diet and had only been out of her house once in nine months before beginning insulin in August 1922. Her weight increased by 9 kg and she had a normal blood sugar before and after breakfast on 10 units of insulin and 25 g carbohydrate. Twenty five years later, Joslin remembered that:

Colonel Palmer, a most brilliant young officer in the Canadian army whose career was shattered by diabetes just before the First World War, came back for insulin. When he saw the children, his first reaction was: ‘Now they make a noise’. Formerly they sat with protruding bellies, silent for hours, resignedly consuming their washed 3% vegetables. Yet today of those feeble creatures there is many a one alive, breathing and standing on his own feet. Von Noorden shuddered and turned aside at the sight of one of them a quarter of a century ago.

The Pissing Evil by Robert Tattersall (HB, £40) is published by Swan & Horn in November 2016

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