This page was last updated 23/6/2006.
This page is about the history of medical equipment: it isn't the place to look for advice on good choices for diabetics alive today - go to the bottom of this page to find some links to such places - including the other pages on the diabetes web-ring. Having problems with this page? Please email webmaster@caerlas.demon.co.uk (or use the form, almost at the bottom of this page), and I'll send you an ascii version.
Want to change the nature of equipment? Here is a link to a piece of academic research . If you are a researcher and would like me to advertise your survey, please ask.
About me: I am a type 1 diabetic, of nearly 30 years. I have a small personal collection of pens, and work as the Museums Development Officer for Surrey Museums Consultative Committee. This page brings together my disability and my vocation. I'm studying part/time at the moment, which makes it difficult for me to keep this page up to date ... apologies ... please come back in 2008 when, I hope, Dr Reynolds will have got around to doing a major overhall ....
"To Help Make the Home Safe for the diabetic is the object"
The seventy-five years since Banting and Best first administered insulin to a diabetic have seen huge changes in the medical approach to diabetes and the anticipated life-span and quality of life of the diabetic. A type 1 (insulin dependent) diabetic myself for 30 years, I have personally experienced some of those changes. In this paper, I attempt to categorize the kinds of equipment used by diabetics themselves (as opposed to equipment used in a clinical setting), and to show how this equipment both reflects the changes in medical approach, and provokes it.
Because Insulin is a protein-based hormone, if taken by mouth it is digested before it can work. The earliest way of getting insulin into the diabetic, a method which is still used today, is the hypodermic syringe. Initially, a wide variety of syringes were used.
Wilder (writing in 1950 in the US) mentions U40 and U80 syringes (the two
strengths of insulin commonly in use then), with red and green scales, and vials
and boxes which were similarly colour-coded. In the UK, as well as single-scale
syringes, some syringes were multi-scaled. Today, it is the type of insulin,
rather than the strength which is colour-coded: U100 insulin being almost
universally used.
Wilder lists the equipment needed as two syringes (one kept ready to use, the
other a spare), six rustless hypodermic needles. 3/8 inch, 25 gauge, a
cylindrical glass tube, and a wood block to stand it in. A wad of cotton, and
the syringe (with needle on) was placed in the tube, which was filled with
alcohol, and corked to prevent evaporation. A strong cotton thread had been
attached to the syringe, so that it could be easily retrieved.
My glass syringe (in the 1970s) was stored in what had originally been a blue
plastic holder - it faded to a bluey grey. There was a spring in the bottom, so
the needle did not actually touch the bottom. The same spring raised the syringe
above the top of the container, once the lid was unscrewed, making the thread
redundant. The holder was filled with industrial methylated spirits
In 1955 Walker mentions that the BS1619 (available in 1ml and 1.5ml versions; Wilder mentions a 2ml U80 syringe) is the syringe in most common use. Over the next decade, it became virtually universal.
Walker notes "Patients attending diabetic clinics should present their syringe for examination regularly". This was for two reasons: first, many complications could arise from dirty syringes, and second, a loose plunger would result in an inaccurate dose. As well as storage in alcohol, the syringe (and needles) - in the early 1970s - were regularly boiled. This (in my house) was in an ordinary domestic saucepan, the syringe wrapped in cotton strip - from an old sheet or pillow-case.
Those six needles were re-used, many, many times, of course. They were sharpened on glass-paper. Disposable needles were a major breakthrough. I cannot remember whether my first needles were disposable, but I think not. While marked 'single use only', disposable needles could be re-used a number of times.
Walker (1955) also illustrates and describes the Palmer injection gun. "I find that new diabetics like the 'gun' very much, but for some reason veteran diabetics prefer to give their injection by simple pushing". The gun, the size and shape of a pistol or revolver, had two sprung clips which held the loaded syringe. The spring was released by a trigger, and the hypodermic was shot in at the correct angle, to the correct depth. The advantage, beyond that consistency was psychological: pulling a trigger being easier than pushing a syringe. On the other hand, when one is in control of the syringe, one can move the needle away from nerves. A current (2000) version is the Haselmeier Autoinjector which shoots the Becton Dickinson 0.5 ml or 1 ml Hypack syringes.
Sandler and Sandler writing in the early 1970s recommend disposable syringes. In Britain these were available on prescription for Diabetics from the early 1980s, and, I seem to remember that this was as a response to the setting up of 'needle exchange' programmes for drug addicts (the argument going that if drug addicts got them free, 'innocent' diabetics should have them too). Early plastic syringes replaced glass ones: that is, they were separate from the needles. From the late 1970s (I think) they were manufactured as a piece.
Needles have got a lot thinner since the 25 gauge ones of the 1950s: 29g is now prescribed in Britain, and 30g is available in the US. They have also been given increasingly slippery, and hence less painful, coatings. But the coatings do mean that the re-use of needles makes subsequent injections more painful than the mere blunting would suggest.
An alternative to the syringe was invented early in the 1980s. These are the 'pen' insulin delivery systems. They are rather like ink cartridge pens in design. They contain a cartridge of insulin - usually 1.5ml, although 3ml cartridges and pens, first intruduced in the mid-90s are becoming much more common. Pens work on a ratchet mechanism to prime a plunger. They produce an audible 'click' when you dial up a unit, and thus they are very useful for diabetics with poor sight. They are also very convenient - if you know you only want a single shot, or are prepared to re-use the needle, all you need to carry is something the size of a large pen. Also, 30g needles can be purchased, in the UK, for pens - and 30g needles are not available on syringes. Haselmeier GmbH & Co manufacture the 'Softpen', and disposable 'penlet' which have hidden needles, and are used by the needle-phobic.
On 1st March 2000 pens and pen needles were placed on the UK prescription list (since insulin-using diabetics get free prescriptions, this effectively made pens and their needles free. However, this was not all good news, as the British Diabetic Association used this action as a 'trade-off' against not fighting the implementation of European Legislation which restricting driving licences (not implemented in all EU countries!) AND as a reason for not actively campaigning for pumps at the same time.) There were some glitches in the early days: I was forced to buy my last pack of pen needles on 5th March 2000.
Another innovation which has not caught on so much here as in America and some European countries is the disposable pen. Syringes are still used, because not all kinds of insulin are available in cartridges, and cartridges only contain one kind of insulin: people using more than one kind of insulin sometimes prefer to take two pen shots, sometimes prefer to mix the insulins in a single syringe shot.
In 1989 Novo launched the NovoLet® the world's first prefilled insulin syringe. It was not widely used.
Naturally, some people never get to like syringes, and jet injectors were the first response to this. I think these were developed in the 1970s. Other alternatives including Dermal PowderJect and inhaler systems are currently undergoing trials, and there are plans to use patches, and to encapsulate insulin so that it is not destroyed by digestion.
In the UK Insulin pump was developed by a team lead by Professor Harry Keen and Dr. John Pickup at Guys Hospital, London. There is a history of pumps n the UK by one of the manufacturers' agents here. Canadian television broadcast a short piece on the invention, and this is viewable here.
Early experimental centres, such as Guys, London, Newcastle Royal Infirmary and Sheffield Hallamshire Hospital discovered some problems with pumps. Reliability in particular seems to have been a problem. It is roumoured that poor design of experiments (rather than poor equipment) actually lead to some fatalities. Partly as a result of the percieved lack of overall benefit, and partly due to their cost, which could not be met by the National Health Service, development in the UK ceased. However, insulin pumps are common today in the USA, where they are paid for by insurance, in several EU countries and elsewhere. In the UK, in 2002, when I got my pump they were used by a few hundred patients, some from the original trials, some on trials which were re-started in the late 1990s, some as "choice of last resort". Following an examination of the effectiveness of pumps, and the listing of criteria, they can be prescribed as a "last resort" in England and Wales, and their numbers are rising.
Disposable insulin pumps are (early 2000) rumoured to be available on the US market. It appears that they are designed to be used by type 2 diabetics, requiring a one-level basal rate, but not intellectually capable of managing a conventional pump, or not needing the multi-basal capabilities of a conventional pump.
Implanted insulin pumps are the next generation. It begs the whole question of what is 'domestic' equipment, if it is implanted surgically.
Another way of looking at the problem has been current for the last 30 years, although with few domestic products in the UK. In 1970 John A. Colwell of Northwestern Medical School proposed "an artificial pancreas", declaring it an "optimistic" idea, but "not completely unrealistic", he thought, however, that pancreas transplantation was more possible: and indeed, that has happened. Pfeifer, Thum and Clemens, in 1974, proposed 'an artificial beta-cell' which they described as 'a closed loop' - that is, a system which, like the pancreas' own beta cells, could both detect the body's need for insulin, and supply it. There has been more successful work on the supply side than on the need. Only two years later Deckert and Lorup developed an intravenous supply. And in 1978 Albisser et al developed a subcutaneous, preprogrammed open loop infusion system.
Late in 1999 Minimed achieved fda approval for a blood glucose monitoring device which sits on the surface of the skin, and is in operation 24 hours a day. Currently available only for doctors to download, it is envisioned that the meter will become part of a closed loop system, and the current generation of minimed pumps is equipped to be part of such a system
The other side of the 'loop' is detecting the need for insulin. How does the diabetic know whether their blood glucose level is normal, high or low? Largely by 'feel'. But there has always been a need for an objective test.
The test used for over forty years was Benedicts Qualitative Test. This looks at the amount of glucose which the kidneys have scrubbed out of the blood and dumped in the urine. Wilder lists the equipment needed for the test: Benedicts qualitative solution, two test-tubes (one to use, one for spare), a medicine dropper, and a source of heat. (an alcohol lamp, or 7« grain tablets of methanamine - these burnt, when lighted, "giving a small flame like that of an alcohol lamp". A teaspoon of the solution was placed in the test-tube, and 8 drops of urine added. The test-tube was either heated in a pan of water, or over a naked flame. The solution turned a colour - from green to orange to brick red, depending on how much sugar was present.
Rachel Mayer Cobb, who was diagnosed in 1931 recalls in her autobiography that she had to take her urine to a laboratory for analysis. Since she was working as a dietician, I am unsure whether this was typical, or whether just practical in her circumstances. Whichever, home use of the Bendect's test became common.
Wilder, writing in 1955 in America, also mentions Ames self-heating tablets, 'the Clinitest'. This was a lot simpler: 5 drops of urine and ten of water were placed in a special test-tube which was set on a stand. A self-heating tablet was shaken into the cap of the bottle (the tablets contained caustic soda), and transferred into the test-tube. When the boiling stopped, one waited 15 seconds, shook the tube, and then noted the colour - which ranged from the blue for no sugar, to orange for 'much sugar'.
The Wellcome Institute Library has a 1960s Ames catalogue which contains Labstix. But when I was diagnosed in 1970, I used the Ames self-heating tablets.
Labstix, Clinistix and tes-tape all did the same thing: they took the boiling out of urine testing. Instead, all one did was pass the strip through your urine flow, knock off any excess, and after a few seconds, note the colour.
But there are drawbacks with measuring glucose in urine - including the fact that it does not show low, as opposed to not high, blood glucose levels, and that different individuals spill glucose into the urine at different blood glucose levels. Some diabetics lament the passing of tes-tape, not for home urine analysis, but for use while eating out: this is a cheap and effective way of finding out whether a fast-food restaurant really has served you a diet cola - or something which will make your blood glucose rocket.
The advantages of being able to measure one's own blood glucose are evident. Laboratory measurement has been possible since before insulin was available. To mention three names credited with the isolation of insulin: Paulesco used Pfliiger's method to estimate the percentage of glucose in the blood this used 25ml of blood. Banting and Best used the Lewis-Benedict method: this used a mere 0.2ml.
Sight-read strips were, I think, first available in the late 1970s, and home-use blood glucose monitors were first marketed, a year or so after. The Glucocheck meter was the first to have a memory, in 1983. In the 1990s, meters have been developed which interface with computers. There are specialised computer programmes which analyse the data captured by the meter. Some programmes also allow for the manual entry of other information, such as diet, and some also analyse the diet.
The drop of blood needed for each measurement is obtained with a lancets. These are the same as are used in clinical situations. The repeated nature of the diabetics sampling has perhaps contributed to the development of a device which I call a lancet-whanger. The most sophisticated is the SoftClix, which has ten depth settings, and uses the most engineered lancet. All lancet whangers have the same basic action: the lancet is a sharp piece of metal in a plastic holder, the whanger has a spring action, released by a trigger. Even veteran finger-prickers tend to prefer lancet-whangers to manual operation - perhaps because the lancet goes in so little, and for such a short time that pain-avoidance isn't an issue.
When a diabetic's blood glucose goes too low, at early levels, a wide variety of substances are eaten to bring it back to normal levels. Common are high-glucose or high-sucrose substances such as glucose tablets, sugar lumps and orange juice. For a just-conscious diabetic (who can still safely be given food by mouth, but who may be rejecting the idea quite violently) tubes of honey, or little tubes of gel for writing on iced cakes can be used. For the curator, these items present a problem - often such items are indistinguishable from the ordinary household items.
Clearly not household items are 'hypo-stop' - a dextrose gel, for administration to the just-conscious diabetic, and Glucagon - a substance which makes the liver release its stored glucose. Kits were available by 1980 which included dried glucagon, an syringe and needle to administer it. This has the advantage that it can be given to unconscious patients by their friends and relatives.
In addition to insulin, equipment to administer it, a means of detecting
blood glucose levels, and means of raising the blood glucose in an emergency,
other items of a diabetic's 'kit' include plasters (not for injections, but for
finger-pricks), and record books. Until the 1980s, diabetics also carried swabs
for cleaning the skin prior to injections (his was until a study found that the
cracks caused by repeated swabbing with alcohol lead to more infections at
injection sites than basic soap-and-water hygiene).
Wilder (1950) records that "A convenient pocket case of bakelite is
manufactured by Becton, Dickinson and Company for the 1cc syringe of the type
described. The syringe fits into a cylindrical watertight holder containing
alcohol, and receptacles are provided for keeping needles in alcohol, and for a
small amount of cotton and one bottle of insulin. The case is labelled 'B-D
Diabetic Outfit with Syringe'."
Walker, 1955, reports "Messrs Allen and Harding make a strong and useful japanned box containing space for syringe, needles, insulin and spirit for disinfection". Blood glucose meter and insulin pen manufacturers usually sell or give away a more or less useful kit holder. The best kit holder I have ever had was another of those items which cross-over from 'normal household' to 'medical': a quilted black make-up brush holder made by Boots. Sadly, I changed meter from a pen-shape one, to one which doesn't fit in the holder. Because insulin is temperature-sensitive, some diabetics use thermally protected bags which are specifically marketed; others use bags designed for carrying sandwiches.
Having a condition which can leave one unconscious, or acting drunkenly makes carrying some form of identification useful. Medic-alert identification and cards issued by bodies such as the British Diabetic Association are carried by many. Those who have not lost their fashion sense might prefer to visit Lauren's Hope. This is another avenue for research.
I mentioned several instances of normal household things being used as medical equipment. The reverse is also true: insulin syringes come in useful for getting small amounts of liquid into things other than human bodies, for example - several of my old syringes went to clock-makers. And insulin pen needles are really excellent at clearing out blocked windscreen ducts.
In 1922, insulin treatment was a matter for research laboratories, not the
hospital, let alone homes. But this changed rapidly: for example, the Paediatric
Clinic of the University of Vienna began to treat diabetics with insulin in
1923. In the period up to 1935, new diabetics on average received 18 months
in-patient treatment. But the out-patient clinic was established in 1924.
Elliot
Joslin in A Diabetic Manual for the Mutual Use of Doctor and Patient in 1924
dedicated his work thus: "To Help Make the Home Safe for the diabetic is the object of
this book" 
The illustrations show test-tubes and measurement scales which a
laboratory technician would recognise, but a cook would not. There is a whole
sub-text here of sterilizing the home, making it as safe as the hospital ward.
But in the title Joslin refers to 'mutual use'. More than many other diseases
and conditions, diabetes is a balancing act, and once balance is between the
roles of patient and doctor, and between 'the equipment' as objects prescribed
by a doctor and used by a patient, and 'the equipment' as being those parts of
late 20th century material culture which are associated, inter alia, with things
diabetics have to do. Over the last twenty years, there has been increasing
'domestication' of diabetic's equipment. The styling and overall design of
equipment is more reminiscent of Marks and Spencer or WH Smith than the local
General Hospital. Diabetics appear to like this. It is one reason, I think, for
the popularity of the insulin delivery pen. An advert for the Novopen 1.5, for
example, compared it to a German car. But perhaps the fact that it is not a
syringe, with all the overtones of drug misuse that that object brings is as
important as what it is.
'Domestication' is happening in other areas of medical equipment too. Wheelchairs are another case in point, and cartoon-character caps for inhalers used by children with asthma have just been launched. 'Domestication' is perhaps the wrong word: it is not so much that diabetic's equipment now embodies the design values of things found around the home, rather than the laboratory, but that over the last 75 years, there has been a complete change of the view. In 1923, the diabetic was envisioned as a hospital in-patient (or sent home to die). In 1998, the diabetic is unlikely to be in hospital, or even at home a great deal - they are at school, at work, out in the wide world. The medical effectiveness of the equipment is taken for granted, and choice made on the basis of features and style.
Well, that's it for now (life to lead and all that!). Please email me, or write your email address in the box below, if you would like to send me a photo of something, make a link to your collection, talk to me about your meth-burner days: pat@caerlas.demon.co.uk - please remember to include your email address in your message- sending me your message only sends the "@aol.com or @umist.ac.uk bit of your address! Of course, if you don't want a reply, you don't need to let me know your address!
Many thank for your comments and questions (did you remember to include your email address?)
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This page is about the history of medical equipment: it isn't the place to look for advice on good choices for diabetics alive today - here are some links to such places:
International Diabetes Institute One of the best diabetes sites in the world: if it isn't here, there'll be a link to it.
Children with diabetes This page is one of the most comprehensive sources of information for diabetics and isn't just for children or type 1s
On-line Diabetes Resources Rick Mendosa has been " Tracking Diabetes on the Web Since February 1995" - this is an excellent set of links.
British Diabetic Association This has lots of useful links
Insulin Pumpmers UK website has information for those using, or thinking about pumps.