A FORCE OF MAGICAL ACTIVITY - THE INTRODUCTION OF INSULIN-TREATMENT IN BRITAIN 1922-1926

The discovery of insulin by Banting and Best In 1921 is the subject of many papers and one authoritative book (Bliss M. The Discovery of Ins ulin. Chicago: University of Chicago Press, 1982. See also Bliss M. Re writing medical history: Charles Best and the Banting and Best myth. I Med Hist 1993; 48: 253-274.). This paper charts the introduction of i nsulin in England and examines its effect on medical practice. Before 1922 there were few effective drugs and only one (thyroid extract) whi ch had to be taken continuously. Insulin was radically different; it r estored weight and vigour and allowed survival in diabetic coma and af ter surgery but was potentially dangerous because of the possibility o f hypoglycaemia, had to be given by injection, and the dose varied wit h the amount of food and exercise. The immediate questions to be answe red after the supply of insulin was assured were how could such a powe rful drug be kept out of the hands of ignorant people (a phrase used b y The Times), who would administer it, and who would supervise the tre atment? Within a year further problems were identified. Should the aim s of treatment be the same as those in the starvation era? Could the d iet be liberalized? How much biochemical monitoring was necessary? I s et the scene by describing how, from Minkowski's announcement (1889) t hat pancreatectomy caused severe diabetes, most clinicians and physiol ogists believed that the pancreas (and specifically the islets of Lang erhans) produced an internal secretion which controlled carbohydrate m etabolism. After Murray's (1891) demonstration that myxoedema could be cured by thyroid extract, it was assumed that diabetes would soon yie ld in the same way. Yet by the beginning of the first World War most e xperts were pessimistic about isolating the hypothetical internal secr etion and had pinned their hopes on starvation treatment. In the decad e before the introduction of insulin the management of diabetes was gr im; patients were kept in hospital for weeks or months, while their ca lorie intake and glucose excretion was meticulously recorded. They wer e in the wards of physicians with a strong interest in biochemistry wh ose forte was analysing urine not looking after patients. When the Med ical Research Council set up a multicentre trial of insulin in late 19 22 they enrolled the physician biochemists who produced the early publ ications and became the experts. The narrow views and innate conservat ism of these doctors with the inflexibility of the system in (London) teaching hospitals meant that insulin treatment became a straightjacke t for many patients. One of the few who adapted the treatment to the p atient rather than vice versa was Dr Robin Lawrence, who himself start ed insulin treatment in 1923 and learned with his patients. At first t he cost of insulin was high and there was concern that it would be use d wastefully and that, if patients were given free rein, they would su ccumb to gluttony, It was hoped that diabetes was a simple functional weakness of the islands of Langerhans; if so, it was argued, pancreati c rest with insulin might lead to full recovery. The first, very malno urished, patients were treated with small doses to produce an average weight gain of 1lb in 15 days. There was a fear that with time insulin would lose its effectiveness but this soon proved groundless. Whether frequent blood sugar measurements were necessary was much debated but it was soon obvious that they were impractical. Hypoglycaemia was see n as a major danger by some physicians and it was worry about such a d angerous side effect and their inability to measure blood sugar which probably dissuaded general practitioners from initiating or supervisin g the new treatment. Insulin became generally available in June 1923 a nd within 3 years most of the principles which guide treatment today h ad been formulated, together with areas of controversy such as: Should normal blood sugars be the aim of treatment? Was alkali beneficial or dangerous in the treatment of coma?