Diabetes
Diabetes mellitus (1)is absolute or relative deficiency of the pancreatic hormone insulin, resulting in high blood glucose levels. It is the commonest endocrine disorder, and its many complications include polyuria, dehydration, coma, pregnancy complications, infections, small blood vessel disease (in the eyes, kidneys and peripheral nerves) and large blood vessel disease (coronary heart disease, stroke and peripheral arterial disease).
Type 1 and Type 2
- The onset of Type 1 diabetes is most often in children and younger adults, but it can present at any age. It is due to absolute or near absolute insulin deficiency, and was usually fatal until insulin was discovered by Frederick G Banting (Canada) and his supervisor John JR Macleod (Scotland) working in Toronto in 1921; and its commercial production to control blood sugar levels. The first insulin to be used in the UK was manufactured by Medical Research Council laboratories and was being used in Glasgow Royal Infirmary by 1923.
- Type 2 diabetes is due to relative insulin deficiency, and primarily associated with obesity. It occurs predominantly in middle age but is seen increasingly in overweight children. A strong genetic component is present in the development of both types of diabetes. It is treated by diet, weight loss, and antidiabetic drugs including insulin in some cases. The global epidemic of overweight, obesity and diabetes over the last 70 years has become a major cause of disability and death.
Diabetes in Children
At the Royal Hospital for Sick Children, Yorkhill, Dr James Oman Craig was the first specialist in diabetes. He wrote a classical textbook on Diabetes in Children, and established a Scotland-wide discussion group, which later developed into the Scottish Study Group for Care of Diabetes in the Young (see below, Western Infirmary).
After his retiral, the Diabetes service continued under Joyce Richardson, and then Malcolm Donaldson.
Royal Infirmary
Alex H Imrie was appointed in 1958, a time when the first effective new drugs for type 2 diabetes – metformin and the sulphonylureas – were becoming available. He was instrumental in establishing a formal diabetic clinic and, by the time of his retirement, had built up the largest clinic in the city.
William G Manderson (1919-2002) was a Glasgow graduate consultant physician (1959-1984). His special interest was diabetes and for 11 years he was in administrative charge of the diabetes service. In 1961, he established a successful medical service for staff and students in the merging University of Strathclyde, situated close to the Royal Infirmary. This University appointed him as its first honorary professor in 1978. He played a major role in the Royal College of Physicians and Surgeons of Glasgow as a member of the joint examining board when the three UK Royal Colleges of Physicians introduced their common MRCP examination in 1970. In his youth, he played football for Queen’s Park with occasional games for Glasgow Rangers. He was chair of the Glasgow Humane Society, and founder of the Friends of the Glasgow Humane Society.
Angus C MacCuish was appointed to the Infirmary and the Royal Maternity Hospital as consultant physician with a special interest in diabetes (1975-2000). He instituted a modern diabetic service with a clinic for adolescent patients, and developed a retinal screening service for detection of diabetic eye disease. In 1988, he oversaw the creation in the Infirmary of a purpose-built Diabetes Centre with permanent staffing by nurse specialists, a podiatrist and dietician as well as medical staff. Monies to construct the centre were accrued from charitable funds and extensive research projects, including the earliest studies of the new human (biosynthetic) insulins for type 1diabetes. In the Maternity hospital, he established a combined obstetric/diabetic clinic with Burnett Lunan and specialist nursing staff, supervising pregnant women to maintain diabetic control throughout the pregnancy at levels that were not injurious to the fetus.
Kenneth R Patterson, a Glasgow graduate, was appointed consultant physician with an interest in diabetes (1986-2011). He formed the Glasgow Local Diabetes Services Advisory Group, and chaired a SIGN guideline for diabetic renal disease. He chaired the British Diabetic Association’s Professional Advisory Committee and Project Grant Committee, and served on the Council of the European Association for Study of Diabetes. He was Honorary Secretary of the Royal College of Physicians and Surgeons of Glasgow (2001-4); and Clinical Director of Medicine for North East Glasgow (2006-8). His other interest was Clinical Pharmacology and Therapeutics, and he was Vice Chair of the Glasgow Drugs and Therapeutics Committee, becoming Chair of the Scottish Medicines Committee in 2004, and Chair of the SMC (2008-11). He was awarded a personal chair.
Miles Fisher was appointed consultant physician in medicine and diabetes at the Royal Alexandra Infirmary, Paisley in 1990; then moved to Glasgow Royal Infirmary, retiring partially in 2018. He researched in premature atherosclerotic disease in persons witn diabetes, investigating the roles of beta-blockers and drugs affecting the renin-angiotensin system. He also studied the thiazolidinediones and their anti-iflammatory effects. Finally he explored the use of glucagon-like peptide 1 receptor agonists in cardiovascular prevention.
Mike Lean was appointed Senior Lecturer (1990) and then Professor (1992) of Human Nutrition in Glasgow University as well as consultant physician with an interest in obesity and diabetes at the Royal Infirmary (see Human Nutrition). In 2017, with Roy Taylor in Newcastle, he published DIRECT, a community-based randomised trial showing that replacing food with liquid meals to achieve radical weight loss (up to 15 kg) can reverse most cases of type 2 diabetes that have been established less than seven years.
Naveed Sattar, a Glasgow graduate, trained in pathological biochemistry and metabolic medicine, was appointed Professor of Metabolic Medicine in Glasgow University (2005). He has researched extensively in cardiometabolic medicine, and has contributed via major epidemiological papers to better understanding of the causes and risks of diabetes. He has also contributed to several trials in the diabetes area and to UK and European guidelines, including SIGN guidelines (see Pathological Biochemistry and Cardiovascular Disease).
John R Petrie was appointed Professor of Diabetic Medicine in Glasgow University in 2010 and consultant physician, Royal Infirmary. Having trained in Glasgow, he was Reader in Diabetic Medicine at Dundee University (2003) where he established the Scottish Diabetes Research Network (SDRN), harnessing data from all people with diabetes in Scotland for nationwide epidemiological research. He was President of the European Group for the Study of Insulin Resistance (2010-15). In 2010 and 2017, he developed algorithms to guide the use of glucose-lowering therapies, within the SIGN guidelines on type 2 diabetes. In 2017, he published the international REMOVAL trial of metformin in type 1 diabetes – the largest and longest double-blind clinical trial to date, shifting attention from the metabolic to the cardiovascular protective properties of metformin.
Western Infirmary
The Diabetic Clinic at the Western Infirmary was established by James Allan.
Michael Small, a Glasgow graduate, was appointed as consultant in administrative charge of the Diabetes Services for West Glasgow (1987-2016). He greatly expanded both the staffing and the services for patients with diabetes, and oversaw the creation of a large purpose-built Diabetes Centre in Gartnavel Hospital in 1992.
The centre
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was quick to establish on-site testing for haemoglobin A1c and microalbuminuria;
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started patient models for type 2 then type 1 diabetes;
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became the centre for insulin pump services in Glasgow.
Young patient clinics were started and Dr Small was the President of the Scottish Study Group for Care of Diabetes in the Young (1999-2001), which aimed at bringing adult and paediatric teams together to discuss care and clinical research.
He chaired the SIGN guideline group on young people with diabetes. Small also worked with the Health Technology Board for Scotland on retinal screening (2001-2002) and helped write the first Diabetes National Framework for Scotland (2001-2002).
He was the Chair of Diabetes UK in Scotland (2000-2008); a trustee of Diabetes UK; and worked with Quality Improvement for Scotland from 2002 including as Chair of the National Diabetes Service reviews across Scotland (2005-2007) – a stimulus to improve care in Scotland.
Victoria Infirmary
The Victoria Infirmary diabetes service was started by Dr Alec Glen, appointed in 1922. This was the year in which insulin was discovered, and he personally undertook the numerous blood sugar estimations required to monitor the increasing number of patients treated with it. The hospital’s Biochemistry Department grew out of this work and, in later years, Glen’s son, Alastair, would become its departmental head. In 1923, Glen was invited to give the first formal demonstration of the use of insulin in Glasgow (Glen A. In the front line: a doctor in war and peace. Edinburgh: Birlinn 2013). In 1937, he was joined by Dr Ian Murray as assistant physician who succeeded him as physician in charge of wards and of the diabetes service in 1955.
Murray served on the executive council of the British Diabetic Association (BDA), became a vice-president, and was a founder member of the International Diabetes Federation in 1950 (Murray I. The Victoria Infirmary of Glasgow; history of a voluntary hospital 1890-1948. Glasgow: Wright 1967). He wrote a book on diabetes, Good health with diabetes, which ran to four editions. He retired in 1964 and Dr Michael Riddell, succeeded him as physician-in-charge of the diabetes and endocrine service. Murray, Riddell and Dr Ian Wang, the hospital’s clinical haematologist who assisted at the diabetic clinic, jointly published one of the first papers on the use of the oral sulphonylurea, chlorpropamide, in 1958 in the Lancet. Riddell retired in 1979, to be succeeded by Dr Stefan Slater. Two years later Slater was joined by Dr Colin Kesson when Wang retired.
Together, Slater and Kesson, both specialty trained, established a modern diabetes unit with dedicated diabetes specialist nurses and dieticians. Kesson led in the computerisation of the clinic records and on other developments within the unit. Both encouraged their juniors in writing papers and the unit was recognised for higher specialty training in diabetes and endocrinology. Slater was a member of the medical and scientific section committee of the BDA and, with Dr Bill Manderson of Glasgow Royal Infirmary, founded the Strathclyde Diabetic Group in 1981 (Slater SD. The Strathclyde Diabetic Group. Glasgow Medicine 1986;3:9-10). 
This drew members from all 18 diabetic units across the West of Scotland. He was its first honorary secretary and, later, chairman. It appears to have been the first multidisciplinary group of its kind in the UK, comprising not just physicians and ophthalmologists and gynaecologists interested in diabetes, but also diabetes specialist nurses, dieticians, podiatrists, biochemists and pharmacologists. It published two influential papers on the safe reuse of plastic disposable syringes and needles. Slater, with Dr Anthony Swerdlow, epidemiologist, also began establishing in 1983 a cohort of insulin-treated diabetics in the West of Scotland for long-term study of mortality and morbidity. This cohort, with cooperation from diabetic units in England, ultimately numbered about 36,000 patients, then the largest such cohort ever assembled. Several publications followed, with Slater as lead clinician, including two on all-cause and cause-specific mortality, which were regarded as “landmark” studies. For several years, Slater was specialty adviser in diabetes and endocrinology to the National Medical Advisory Committee of the then Scottish Office Home and Health Department.
In 1990, Slater co-edited with Derek Dow, historian, The Victoria Infirmary of Glasgow 1890-1990: a centenary history. He also served as the first deputy honorary secretary of the Royal College of Physicians and Surgeons of Glasgow (1992-95), then as honorary secretary, (1995-98). He chaired the College’s quatercentenary committee (1993-99), planning the celebratory events for its 400th anniversary in 1999. These included a conference on Medicine & Literature and an exhibition on Medicine & Art. In association with the conference, he organised a short story competition, open internationally to doctors and medical students, which was supported by the British Medical Journal. The 16 best entries were published as The Magic Bullet and other medical stories.
As the hospital’s diabetes service grew, it acquired a third consultant physician with a special interest in diabetes and endocrinology. This was Dr Chris Thompson, followed by Dr Desmond Rooney when Thompson moved to the Beaumont Hospital, Dublin, where he became Professor of Endocrinology. Desmond Rooney moved to Northern Ireland and was succeeded by Dr Andrew Gallacher.
Slater retired in 2001, to be replaced by two part-time consultants, Dr Helen Hopkinson and Dr Alison Stewart. Kesson retired in 2005 to be succeeded by Dr John Hinnie. The Victoria Infirmary closed in 2015, with all inpatient services transferring to the new Queen Elizabeth University Hospital at the Southern General Hospital site. However, outpatient facilities, including diabetic and endocrine clinics, are still available locally in South-East Glasgow in the new large ambulatory care facility built opposite the old Victoria Infirmary grounds.
Southern General Hospital
John Ireland was appointed consultant in 1968 and rapidly established a formal diabetic clinic. A man of immense energy, his contributions to modern diabetes care were outstanding and twofold: he was the founding editor of Diabetic Medicine, the standard journal for published diabetes research in the UK, and he developed the pen system for insulin injection that is now used world-wide. He also authored two textbooks on diabetes. He died in 1987 at 55. The Scottish Committee of the British Diabetes Association (now Diabetes UK) established an annual award in his memory for an individual who has served the diabetes community in Scotland with distinction. For the story of the development of the insulin pen, see “The pen is mightier…." He was succeeded by Colin Semple.
The pen is mightier..
Stobhill Hospital
James Neilson was in charge of the diabetes clinic in Stobhill hospital from 1964. Donald McLarty also ran the diabetes clinic until he emigrated to Dar es Salaam in Tanzania in 1977. They were succeeded by Hamish MacLaren and Derek Gordon.
Angus MacCuish, John Petrie, Naveed Sattar, Stefan Slater and Michael Small
(1) Diabetes mellitus (‘sweet urine’) is much commoner than diabetes insipidus (‘watery urine’) which is due to deficiency of antidiuretic hormone from the pituitary gland. [back to Diabetes]
Image provided by author
20th Century