Histories of diabetes often claim that the introduction of insulin in 1922 immediately revolutionised the treatment of diabetic ketoacidosis and diabetic pregnancy. How far from the mark this grand narrative of progress is can be seen from the fact that 30 years later, at the time of Queen Elizabeth's accession, a woman with diabetes had slightly better than a 50:50 chance of having a live baby and the mortality of ketoacidosis in many hospitals was 30–50%. Improvement of the prognosis in both conditions was as much due to good organisation as to new scientific principles.
Ten years ago in this journal I wrote that 'many of the conundrums which perplexed diabetes specialists in the early 1950s have now been resolved.' (Tattersall R. The dark ages of diabetes) Those who take a Whiggish view of history may imagine that once a pioneer shows the 'right' way to treat a condition, everyone would immediately follow suit, even without the benefit of NICE guidance. The story of how we reached the modern treatment of diabetes in pregnancy and that of ketoacidosis shows just how wrong this is.