The Rise of Childhood Type 1 Diabetes in the 20th Century

Edwin A.M. Gale

Disclosures

Diabetes. 2002;51(12) 

In This Article

Childhood Diabetes Before Insulin

Diabetes itself was an uncommon diagnosis in the 19th century. The 1892 edition of Osler's Principles and Practice of Medicine devotes 10 pages to diabetes, compared with 65 for tuberculosis, and mentions that only 10 of 35,000 patients treated at Johns Hopkins were affected[4]. Massachusetts General Hospital admitted 47,899 patients over the period 1824-1898, of whom 172 (0.004%) were diagnosed with diabetes. Of these, 18 were diagnosed under 20 years of age and 3 under 10 years of age. Until 1851, diagnosis was based on the taste of the urine, which may have curbed screening enthusiasm, although the physician in charge "sometimes called upon the house physician to apply this test," and self-monitoring was occasionally recommended[5]. Improved access to urine tests probably accounts for the increased frequency of diagnosis from 1885 onwards, and by 1923, urinary glucose measurement was available in many U.S. drugstores at a cost of 1¢ per test[6].

In 1913, the Professor of Pediatrics at the Harvard Medical School had personal knowledge of 19 cases of childhood diabetes. Despite this limited experience, John Lovett Morse, who wrote the first paper on childhood diabetes in English, was able to draw on a fairly extensive literature in German and French dating back to 1878, and his paper provides a helpful overview of the existing world literature. Morse assembled a total of 989 cases from clinical reports and mortality data. Of these, 162 presented before 5 years of age, 302 from 5-9 years of age, and 525 over 10 years of age[7].

Blood glucose remained difficult to measure and did not become a routine part of the work-up of Joslin's patients until 1915[8]. The introduction of the Folin-Wu method in 1920 enabled blood glucose to be measured on a finger-stick sample[9,10]. Even then, blood had to be taken adjacent to the laboratory, since preservatives were not introduced until 1931[11]. Despite reliance on urine tests, the near uniform fatality of childhood-onset cases in series from the preinsulin era testifies that there was little confusion with renal glycosuria. Morse cites Carl von Noorden, the great European authority of the time, who said that "with few exceptions diabetes in childhood knows no cure, no matter how mild it may appear in the beginning, nor how gradual its development in the first months or even years." His experience was that children under age 7 years with the severe form of the disease survived 18 months to 2 years, while those with "mild glycosuria" lived 3-6 years, and that "the usual statement that the younger the child the shorter the course is true"[7]. Joslin reported in 1923 that 86% of children presenting under age 16 years had previously died in ketoacidosis[6].

There is of course no way of knowing how many cases of diabetes had been missed, but one small clue suggests that we should not underestimate the diagnostic skills of our predecessors. A strong family history was already recognized as a favorable prognostic marker, and Joslin remarked that "all cases which have come to my attention of youthful patients with diabetes living for very long periods of time have been hereditary"[6]. If Joslin was familiar with maturity-onset diabetes of the young, as Tattersall believed him to be[12], this could provide useful internal evidence that type 1 diabetes was truly rare.

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