Why diabetes no longer means death

It all happened so fast. In the middle of the night on 31 October 1920 Frederick Banting, a struggling young doctor in Ontario, had an idea about how to treat type 1 diabetes. By May 1921 he had persuaded John Macleod, professor of physiology at the University of Toronto, to let him use a laboratory there to begin animal experiments. In December 1921 they presented their results with dogs to the American Physiological Society. In January 1922 the first human patient was successfully treated with insulin. By late May 1922 Banting and his university colleagues reached an agreement with Eli Lilly and Company to produce insulin from beef and pork pancreases. In October 1923 Banting and Macleod won the Nobel prize in physiology.

Banting, a mediocre 1917 graduate of the University of Toronto’s medical school, had treated soldiers on the front lines in the first world war, been wounded, and been awarded the Military Cross for bravery. Back in Canada he floundered while trying to set up a practice in London, Ontario. Then he had his brilliant idea: that somehow extracts from pancreas could treat diabetes and save patients from certain death.

He hadn’t bothered to research the literature or he would have known that others had had the same idea but that it hadn’t worked, as Macleod, a noted diabetes researcher, told him. Nevertheless Macleod gave him the use of an old laboratory and an assistant, Charles Best, for the summer. It was miserably hot, and the laboratory stank from the faeces of the dogs they worked with. James Collip, a biochemist, joined the team.

Diabetes, as the exhibition reminds you, is an old story. Nearly 2000 years ago Aretaeus of Cappadocia called it “a melting down of the flesh and limbs into urine.” De Succo Pancreatico, or a Physical and Anatomical Treatise on the Nature and Office of Pancreatick Juice, published in London in 1679, described “diabetes, or the pissing evil.” The islets of Langerhans had been identified by 1905.

The exhibition includes historical books, photographs, and early insulin packaging. The accompanying book is meticulously researched but overwritten in trying to be a page turner.

No treatment, including the quack remedies on display, saved patients from death—except the treatment of Frederick Allen, an American specialist who published Studies Concerning Glycosuria and Diabetes in 1913. Allen found that undernutrition of diabetic patients postponed their deaths until the hoped for cure was found. His patients, mostly children, were starved on less than 1000 calories a day interspersed with fasting. They looked skeletal, as photographs in the exhibit show.

“The object of the treatment of diabetes is to supply a diet that can be metabolised and will not overtax the weakened carbohydrate metabolism,” said the Handbook of Therapy, published by the American Medical Association in 1920.

Elliott Joslin, a diabetes researcher and clinician in Boston, Massachusetts, meticulously recorded his patients’ outcomes. His handwritten “diabetic register” for 1921-3, included in the exhibition, showed that they all died. Joslin and Allen followed Banting’s work at the University of Toronto.

The exhibition also focuses on Elizabeth Hughes, one of the first American patients to receive insulin. She was the youngest child of Charles Evans Hughes, who had barely lost the presidential election of 1916 to Woodrow Wilson and who later became US chief justice. Elizabeth, whose diabetes was diagnosed in 1919 when she was 11, was treated with Allen’s starvation diet. A lively and intelligent girl, she wrote cheerful letters from Allen’s sanatorium while her weight dropped to 45 pounds (20 kg).

In August 1922 she was admitted to the Toronto programme. She was given two insulin injections a day, 15-30 minutes before her morning and evening meals. On 1 December she left the Toronto clinic healthy and went on to university, marriage, community work, and three children. She died in 1981, aged 74.

George Clowes and a team at Eli Lilly developed a commercial supply of insulin, with the Indianapolis plant running three shifts a day. A pile of animal pancreases as high as a person produced one small bottle of insulin. By October 1923 Lilly released insulin for use by 7500 doctors to treat 25 000 patients. The exhibition shows a video of insulin production and an insulin injection kit used in 1926. By 1932 sales of insulin had reached nearly 800 million units and the price had dropped by 90% from that of 1923.

As the exhibition emphasises, and as Joslin taught, diabetes requires patients to learn to care for themselves and to live a healthy lifestyle with a balanced diet and exercise. He predicted our current epidemic of diabetes. Patients older than 50, he wrote, “rarely acquire diabetes if their weight remains a little below normal.”

Thomas Farley, New York city’s current health commissioner, notes that the discovery of insulin was “one of the few transforming events in the history of medicine . . . Ironically, nearly a century later, diabetes is a larger problem than ever. More than one million New York City residents have diabetes, resulting in 20 000 hospitalizations, 3000 amputations, and 4700 deaths every year.”

The exhibition closes with a videotape from Nepal highlighting the daunting problem of diabetes in a rural population in a developing country, where brave young people learn to treat their diabetes while hoping to complete their education and help their nation as teachers and nurses.