Читать книгу Unveiling Diabetes - Historical Milestones in Diabetology - Группа авторов - Страница 52

Elliott Proctor Joslin (1869–1962) was born in the small town of Oxford, Massachusetts, into a prosperous family of religious Congregationalists. He received his M.D. from Harvard Medical School. After further training, he opened a private practice in Boston in 1898, became the first doctor in the USA to specialize in diabetes, and was the founder of today’s Joslin Diabetes Center. His book, The Treatment of Diabetes Mellitus [16], went through many editions, indicative of Joslin’s prominence.

A man of deep faith in religion and science, Joslin was frugal but immaculate in dress, rising early, working long hours, and eating sparingly. According to Chris Feudtner, who studied Joslin’s long career, he had a spry body, a serene sense of discipline, and a stern New England conscience. He combined a “gentlemanly manner with a showman’s knack and a preacher’s zeal, always looking to spread his message of diabetic care” [17].

In 1915 the well-established Joslin generously credited the younger Allen for great progress that the period 1914–1915 had seen in the treatment of diabetes mellitus:

The advantage of maintaining the urine sugar-free has been universally recognized, but all have conceded that this was impossible without danger from acidosis and inanition. Fasting and a low diet have been known, but it is only fair to give Allen the credit of first to see the therapeutic significance of inanition upon a severe case of diabetes, second to prove upon diabetic dogs that prolonged fasting would render them sugar-free, and third to have the courage of his convictions and apply this principle to human diabetes. Thanks to Dr. Frederick M. Allen we no longer nurse diabetics – we treat them! [18]

I see no reason to doubt that Joslin was genuinely impressed by Allen’s therapeutic achievements, but there was also a preexisting relationship between the men going back to Allen’s time at Harvard. Joslin was an assistant professor at Harvard Medical School while Allen was a teaching fellow, and they knew one another if only for their shared specialization in diabetes. Dr. Alfred Henderson, who knew both men in their later years, told me that they communicated about patients while both were at Harvard. Also, they were fraternity brothers, members in their respective undergraduate colleges of Alpha Delta Phi, the fraternity of John D. Rockefeller, Jr., and Theodore and Franklin Roosevelt [19]. In the preface to his Harvard University Press book, Allen acknowledges his indebtedness to Joslin for “good offices in connection with publication.” As a fellow at Harvard, Allen received a USD 300 grant for his diabetes work from the medical school’s Proctor Fund, established by bequest of Ellen Osborne Proctor for the study of chronic diseases. Ellen Proctor was Elliott Proctor Joslin’s aunt, and he was instrumental in establishing the fund [20]. In the preface to the 1917 edition of his text, Joslin writes, “I can never repay Dr. Allen’s many and continued kindnesses or sufficiently acknowledge the inspiration which his fruitful and persistent work awakens” [16].

As a consequence of having a large practice in diabetes but few effective tools, Joslin had by 1916 lost 62 patients under the age of 15 years, with coma always the cause of death [21]. In adopting Allen’s treatment, first removing fat, then protein, then carbohydrate from the diet, Joslin forestalled hyperglycemic crises and ketoacidosis that are known today to induce diabetic coma [22]. Quickly noticing the improvement, especially among his child patients, Joslin reported “the gratifying fact” that in the past year, “48 cases (probably mostly adults) have been treated by me in hospitals without a death” [21]. Two years later he would comment, “Whereas formerly the prognosis for children less than ten years of age was measured in months, today it is rare for a child to live for less than one year.” Furthermore, Joslin saw a pragmatic benefit for general practitioners: “The greatest advantage of the fasting treatment introduced by Dr. Allen lies in its simplicity and in the removal of the need for quantitative urinary examinations” [16].

His clinical experience deeply impressed Joslin: “For myself, I consider the impression which I have thus obtained of far more value than any statistics which my records afford, but it is almost my duty to present these as well.” He summarized his cases in tables, but was not an adept statistician. Even his arithmetic is incorrect! (See Mazur [1] for my reanalysis of his case data.) Based on his own cases, starvation did not seriously prolong life, but it did largely eliminate coma as the proximate cause of death. Joslin was jubilant about this, concluding, “I am coming to feel that coma no longer represents the culmination of the disease, but that it is an avoidable accident” [16].

In all his subsequent publications, Joslin praises Allen as the primary innovator in diabetic therapy. The second edition of his textbook, Treatment, opens with Joslin writing, “The advance in the treatment of diabetes, which began with the introduction of fasting by Dr. F. Allen, continues, and statistics are now available to show it. So-called acutely fatal diabetes is disappearing and the first year of diabetes is no longer, as was only too recently the case, the diabetic’s danger zone. Already I have quite a series of patients who have outlived their normal expectation of life at the age of onset of their diabetes.” And later in the text:

Looking back upon the treatment of diabetes before Allen’s introduction of prolonged fasting, it really seems... that our patients were nursed rather than treated. Only those who have cared for many patients by the older methods can appreciate the advance which Allen has given to diabetic therapy. [16]

In February 1916, The New York Times reported a symposium held at the New York Academy of Medicine on the “Allen Plan.” Whether or not Joslin had a hand in setting up this event, he gave it his imprimatur. Dissenters also participated, but the story’s headline, “Radical New Method of Treating Diabetes,” suggests that it was a platform for Allen, who told his colleagues, “Many of our patients run up the eight flights of our stairs at the hospital of the institute twenty times a day. Then they walk eight or ten miles in the open air. They also skip the rope and toss medicine balls. We are making athletes of them, thin as they are, and surely it can at least be said of them they are not neurasthenic” [23]. Poignantly, Joslin later adds “a discouraging nature (of the new treatment), for a new cause of death appears in my records – namely inanition, and to this 3 cases succumbed. Inanition, like coma, may be rightly considered at present as evidence of unsuccessful treatment” [16]. Joslin blamed himself for these deaths.