Elliot Joslin (1870-1962)
Elliot Joslin was born in Oxford, Massachusetts and was educated at Leicester Academy, Yale and Harvard Medical School (1891–1895). Whilst attending the latter, he won the Bolyston Society prize for work later published as The Pathology of Diabetes Mellitus. He trained at the Massachusetts General Hospital and twice studied with leading investigators in metabolism (in Germany and Austria) before entering private practice in 1898. He began at 81 Bay State Road, in the Back Bay section of Boston, where his townhouse and an adjacent building expanded over the next 50 years to accommodate his practice and staff. He moved to what is now known as the Joslin Diabetes Center in 1956.
Elliot JoslinIn 1908, he carried out an extensive series of metabolic balance studies with the physiologist Francis G. Benedict, examining the response to fasting and feeding in patients with diabetes with differing degrees of severity. Despair at the number of his patients who were dying in diabetic ketoacidosis drew him to the observations of Frank Allen. Allen had shown that carbohydrate-restricted diets prolong the lives of animals with experimental diabetes, and went on to show the same in humans. Joslin combined Benedict’s balance study format with the Allen diets to show that ‘undernutrition’ prolonged the life of his patients, who were often near death from infection or acidosis prior to his intervention. The patients were admitted to ‘cottage’ units located in the grounds of the New England Deaconess Hospital, where a partnership with the School of Nursing led to the rigorous training programme that provided him with well-disciplined nurses for the measure-diet programme.
Confident that the new treatment had made a difference, he included findings from 1,000 of his own cases in his 1916 monograph, The Treatment of Diabetes Mellitus. Here he reported that ‘the mortality of patients was approximately 20 percent lower than for the previous year’, due to ‘the introduction of fasting and the emphasis on regular exercise’. This textbook, revised ten times during his lifetime, established Joslin as a world leader in diabetes. He tirelessly alerted other investigators, public health officials and general practitioners to the ‘silent epidemic’ of diabetes. By recording extensive data from his patient records in large ledgers, referred to by his staff as the ‘Black Books’, he maintained an epidemiological chronicle of his patients with diabetes. As he wrote in 1928, his ‘private statistics [had] preceded public statistics’, and the Metropolitan Life Insurance Company used his statistics for their actuarial tables.
His companion volume, Diabetic Manual — for the Doctor and Patient, was first published in 1918, and asked of his patients what he had previously required of his nurses. It became a bestseller, forecasting the modern self-help movement, and served as the syllabus used to educate his patients about their condition. When insulin arrived he sent his nurses out into the community with instructions concerning diet, exercise, foot care and insulin adjustment. These, the forerunners of certified diabetes educators in the US, also helped to pioneer the diabetic children’s camps that started in New England shortly after insulin became available.
Joslin’s practice skyrocketed when insulin became available. He expected his associates and consultants to work as a team, and a large benefaction in 1928 allowed key collaborations to be organised, including publications on limb salvage (involving surgeons, physicians and podiatrists) and the pathology of diabetes complications. Early Caesarean delivery for pregnant mothers with insulin-dependent diabetes emerged from the work of Priscilla White (1900-1989), who created the classification of diabetic pregnancy according to foetal risk. The first hospital blood glucose monitoring system for pre-meal testing, the forerunner of home self-monitoring, was developed under his direction by 1940.
Joslin and his team became identified with the proposal that strict control of blood sugar levels through a restricted carbohydrate diet, exercise and frequent testing and insulin adjustment would prevent vascular complications. This was endlessly and often acrimoniously debated by other investigators, and the American Diabetes Association was divided on this subject from its founding. Opponents often stereotyped Joslin’s group as medical reactionaries, but increasing evidence gradually tempered their criticism and Joslin’s position was finally endorsed by the DCCT in 1993.
Elliot Proctor Joslin remained tirelessly active until he died in his sleep at the age of 92 on 28 January 1962. He had attended church and dictated letters to his patients on the previous day.
^ Barnett DM (1998) Elliott P. Joslin, MD: A centennial portrait. Joslin Diabetes Center, Boston