Is it any wonder that insulin is so difficult to manage?  It is, after all, a young drug, and one that has seen rapid and extraordinary changes in formulation and delivery in the ninety years since discovery. 

Many vaccines, antibiotics, antiseptics, antihistamines, and anesthetics were invented in the 300 years before insulin first made its appearance on the scene.  People were flying, driving cars, listening to radios, riding escalators, vacuuming their carpets, talking on telephones, and enjoying air conditioners before the invention of insulin.  

It is impossible to calculate the number of diabetics who died before Banting and Best and their team discovered and delivered effective insulin in 1922.  When one considers the average incidence is around 6% of the population today, I'm sure we're talking about hundreds of thousands of people, mostly children.  If you've never seen how those people typically died, and you've got a strong stomach, I would suggest looking here.  It's not pretty, it's disturbing, but it certainly instills an appreciation for insulin, as imperfect as it might be.

The first insulin, derived from cows, injected in patients in January of 1922, was about as precise as trying to stab a fly with a pitchfork.  Each vial differed in purity and quality, causing severe hypoglycemia and terrible rashes, calluses, and itching at the injection sights.   

But in the ten years after the initial discovery, companies were licensed to manufacture the drug and proteins were discovered to slow its release, creating, in essence, the first "basal" rate for people living with diabetes.  A disease that just a decade earlier had a 100% mortality rate, with death occurring within years or even months of diagnosis, now had multiple effective treatment methods.

Between the mid-1930s and early 1950s, developments around insulin slowed. The 1950s however, brought multiple forms of long-acting, slow-release insulin with peak times ranging from 10-12 hours and in the case of one type of insulin a constant 24 hour peak.   

Throughout the early years of insulin, sources included bovine and porcine - creating beef, pork, or beef and pork formulations.  In the 1960s, the first synthetic human formulations were developed.   Because of the cost of production, human synthetics were not manufactured for wide use until the late 1980s/early 1990s.  

As a diabetic diagnosed in 1982, I can attest to the difference in control with synthetic human versus beef and pork insulin.  A log book I have from summer 1988 shows the changes in bloodsugar control we had with smaller doses of insulin almost immediately after we switched to human synthetic.  My doses were reduced from around 40 units per day to around 18 units per day.

As if the changes in the drug itself during its short lifecycle weren’t enough, delivery methods have also seen drastic changes.  The first insulin syringes were made of glass, with needles ground on a whetstone for periodic sharpening.  Can you imagine?  Sharpening up your needle before injecting?  The needles were sharpened one or two times each week until they were so worn down they had to be replaced.  Sterilization was achieved through boiling on the stove.  Needles for glass syringes were between 11/2 and 2 inches long when they were purchased.  In the late 1950s, in Europe, the first disposable plastic syringe was patented, but it wasn’t until the early 1970s that the first patent for such a syringe was granted in the United States and disposable syringes were made available to patients.   

In 1978, the first insulin pump made its debut.  It weighed around 30 pounds and was about the size of a small adult-sized camping backpack, in the words of a friend it looks “like a Ghostbusters backpack.”  Clearly, this is a technology that has made an incredible amount of progress in thirty years.  Infusion sets have been improved to better facilitate insulin delivery, pump size has gone from back-sized to palm-sized, programming of doses happens on a screen with menus versus by method of dials and screws.  There are pump systems that are actually tubeless.  And dosing can be reduced to tenths of a unit or less.  

Even this brief history of insulin and delivery methods shows the course the drug has taken in the short time it's been around.  And just as insulin has grown leaps and bounds, so has home glucose testing.  Before the 1970s, urine testing was done with a Bunsen burner.  Yes, a Bunsen burner, like in high school chemistry.  Insulin dosing was largely a guessing game based on the amount of sugar in urine, measured through boiling a mixture of urine and water and dropping in a chemical which turned the mixture colors.  Certain colors meant more or less insulin, or more or less food.   Urine test strips, which measured glucose in urine through a similar chemical process, only cutting out the boiling process in favor of a chemical reaction that happened in pads on these strips, hit the market for patients in the late 1970s.  

In the early 1980s, home blood glucose monitoring became available.  It made a huge difference in patient control, with decisions around dosing now based not on the amount of sugar in urine, but in the blood itself.  The first home glucose tests required large amounts of blood, took several minutes to perform, and were read by human eyes and not glucose meters.  As with urine strips, the pad on the bloodsugar test strips turned color by chemical reaction and bloodsugar was determined by reading the colors on the pads.  By the mid-1980s, the first blood glucose meter was sold on the mass market.  It was a cumbersome piece of equipment, about the size of a brick, and took three minutes to read the test strip.  In the twenty years meters have been around, they’ve been shrunk to the size of a beeper, require far less blood to get an accurate reading, and average acceptable accuracy guidelines have gone from within 45-50% of the actual bloodsugar to within 20%.    The data we’re using to calculate insulin dosing is therefore much more accurate, greatly improving the care and treatment of both type 1 and type 2 diabetes.

With all of these advances, doctors and nurses working with diabetic patients made their way too, gaining understanding and perspective with each new development.  I and many of my peers diagnosed in the late 1970s, early 1980s, benefited greatly not only from burgeoning technology, but from doctors and nurses who were striving to ensure they were giving the best possible advice and guidance.  Even before the real dawn of insulin pump technology, my mother was working with our team from Boston, drawing half units of insulin and quarter units of insulin, giving four daily injections versus two, and spending time and energy ensuring our calculations were getting us close to the results we wanted.     

In 89 years, insulin, insulin delivery methods, and the monitoring of bloodsugar have saved countless lives.  I complain sometimes about what a challenge it is to manage diabetes.  And it is a challenge.  But it is a challenge that just one generation ago was more daunting, a challenge that just one generation ago had often insurmountable odds.  With all of its downsides, modern insulin is magic.  And the pace at which diabetes science has moved is astounding.  

Looking back for me, allows for one thing above all others, it allows for hope.  Hope that the science will keep its pace, hope that in five or ten or fifteen years, we’ll be looking back and saying “it took us just 100 years (or less) to go from a disease with a 100% mortality rate to a REAL cure.”  Hope that I, and those I know living with type 1, will be a part of history, just the way Banting & Best’s patients were, not so long ago, back in 1922.