August 2, 1893

Dr. Joslin Makes First Entry in Diabetic Ledger

PRIMARY SOURCE: Ledger, 1916
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On this day in 1893, a student at Harvard Medical School made the first entry in a ledger he would keep for the rest of his long career. Elliott Joslin examined a frail young Irish girl, who was suffering from diabetes. Long before he became one of the world's leading authorities on diabetes, he understood the importance of careful documentation. Keen observation of his patients helped him develop a novel approach to the treatment of diabetes. He prescribed a strict diet that regulated blood sugar levels and helped patients manage their own care. The introduction of insulin in 1921 confirmed the effectiveness of Joslin's approach. Elliott Joslin saw 15 patients a day until a week before his death in 1962, at age 93.

Eventually, his ledgers filled 80 volumes and became the central registry for diabetes in the United States, the first system for recording patient diabetes data outside of Europe.

Unlike many other men who made Boston a center of medical innovation, Elliott Joslin was born in Massachusetts — in the town of Oxford, 40 miles west of Boston. The son of a wealthy shoe manufacturer, Elliott was an unusually focused, driven young man. He attended Yale College, graduated at the top of his Harvard Medical School class, and served an internship at Massachusetts General Hospital. After additional study in Europe, he returned to Boston in 1898 and opened a private office in the house his father had bought in the Back Bay.

Although Joslin had been interested in diabetes since medical school, he began his career as a general practitioner. Physicians who specialized in one particular disease were still rare in American medicine, and it would be almost 20 years before Elliott Joslin emerged as one of the most influential people in the study and treatment of diabetes.

Mary Higgins's case sparked his interest and convinced him of the need to chart in detail the course of a patient's illness. Joslin began keeping a diabetic ledger in 1893; Mary Higgins was the first entry in the first volume. He documented every patient he treated for the next 70 years. Eventually, his ledgers filled 80 volumes and became the central registry for diabetes in the United States, the first system for recording patient diabetes data outside of Europe.

While Joslin's regimen was unrelenting — one girl remembered being forbidden regular cake and having to settle for one made of soda-biscuit even on her 16th birthday — the benefits were clear.

The eighth patient described in his ledger had special significance for Elliott Joslin: it was his mother, Sara Proctor Joslin, diagnosed with diabetes in 1900. The disease was considered uniformly fatal, but Sara Joslin lived an astonishing 13 years after her diagnosis. She followed her son's instructions to eat a low-carbohydrate, high-fat diet.

In his 1916 textbook, The Treatment of Diabetes Mellitus, Joslin described the disease and the unconventional treatment program he had developed. It emphasized careful control of blood sugar levels, regulated by "scientific" menu plans like the one he had prescribed for his mother. While Joslin's regimen was unrelenting — one girl remembered being forbidden regular cake and having to settle for one made of soda-biscuit even on her 16th birthday — the benefits were clear. His patients lived longer, and he quickly gained a reputation as the leading clinician in the country for the treatment of diabetes. His textbook, now in its 14th edition, is still the standard work on diabetes.

The book included a section, "Aids in the Practical Management of Diabetic Cases," reflecting Joslin's commitment to giving patients the knowledge they would need to help manage their own disease and treatment. While a widely-accepted idea today, teaching the afflicted and their families how to administer personal treatment plans was a radical approach in 1916. Once a patient returned home from the hospital, he or she was assisted by "wandering diabetes nurses," another of Dr. Joslin's innovations.

"If a diabetic with his disease can live longer than his neighbor of the same age without it," Dr. Joslin once said, "I consider that he has attained a distinction, and should be recognized as outstanding."

Elliott Joslin was one of six North American physicians appointed to the committee, organized in the early 1920s, to conduct the first clinical trials of insulin. This gave him access to insulin and a chance to observe its effectiveness. Growing numbers of patients sought him out. In a typical year before insulin, he recorded 200 new cases in his ledger; after insulin became available, the number jumped to nearly 800.

In 1934 a building was opened on the New England Deaconess Hospital site to house research laboratories for Dr. Joslin and colleagues. With a hand-picked team of physicians to assist him, Joslin was able to expand and institutionalize what had been a solo practice for over 20 years.

Joslin and his colleagues continued to look for ways to improve the treatment of diabetes. He understood the importance of giving hope and encouragement to patients and developed the custom, still followed at the Joslin Diabetes Center, of presenting medals to diabetics who brought their disease under control. "If a diabetic with his disease can live longer than his neighbor of the same age without it," Dr. Joslin once said, "I consider that he has attained a distinction, and should be recognized as outstanding."

Joslin was known for his showmanship as well as his medical proficiency.

Joslin was known for his showmanship as well as his medical proficiency. Once he was scheduled to lecture on obesity. When the time came, the podium was empty. After a few moments, the back door of the auditorium opened and the Joslin entered carrying two large buckets of water. He laboriously made his way to the stage, set down the pails, and gave this brief lecture: "This," he told the stunned audience, "is what the obese person does every day and every night of his life."

In 1952 Dr. Joslin's clinic at the Deaconness formally adopted the name that many had used informally for years: The Joslin Clinic. In 1968 the Diabetes Foundation, founded in 1953,was rechristened the Joslin Diabetes Foundation in recognition of Elliott Joslin's incalculable contribution to the study and treatment of the disease. Since 1981, the foundation has been known as the Joslin Diabetes Center.

If You Go

Joslin Diabetes Center is located in the Longwood Medical Area. Dr. Joslin's former home and the first location of his Diabetes Clinic still stands at 81 Bay State Road in Boston's Back Bay.

Location

This Mass Moment occurred in the Greater Boston region of Massachusetts.

Sources

"A Tradition of Teaching the World About Diabetes," Hospital Management Profiles (1997, Issue 1).

"Remembering Dr. Joslin," by Leo P. Krall, Hospital Management Profiles (1997, Issue 1).

Elliott P. Joslin, MD: A Centennial Portrait, by Donald M. Barnett (Joslin Diabetes Center, 1998).

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