TWENTY–FIVE

Fame and Famine, Summer 1922

EVER SINCE THE AAP MEETING IN MAY NEWSPAPERS AROUND THE world heralded insulin as a miracle cure, saying that it would do for diabetics what antitoxin had done for those with diphtheria at the turn of the century. The inevitable result was that in July, the Toronto train stations teemed with emaciated children and their distraught families, drawn by the stories in the press. Best went to Maine for a vacation, and once again Banting found himself alone in Toronto’s sweltering summer climate. Each day’s mail contained a deluge of desperate entreaties. One envelope was simply addressed: “To the Dr. who cures Diabetes, Toronto, Ont.” A daily pageantry of illness filed up Bloor Street West to the tiny waiting room of his clinical office. Each child’s distended stomach and huge staring eyes were more heartrending than the last, but there was no stable, nontoxic insulin. It was an excruciating conflict: He had agreed not to accept any new patients in his private practice once the diabetic ward at Toronto General Hospital was open, but it wasn’t yet open. In the meantime, didn’t the Hippocratic oath require him to do what he could to help these children? That month Antoinette Hughes’s letter was one of dozens of desperate entreaties that arrived at Banting’s Bloor Street office, either directly or via Macleod. Some came from family members and others from physicians. A typical exchange, as terse as it was tragic, was this one, via telegram, with a doctor in Atlanta:

Dr. J. R. Macleod — Is there any possible chance for you to take Graves Smith the patient about whom Joslin wrote you some weeks ago any time soon[?] His father is anxious to bring him to you if there is any hope of getting him under Banting[.] The boy is in a very serious condition and unless something is done soon it will be too late please wire at my expense.—Dr. J. E. Paullin

Dr. J. E. Paullin — No insulin available at present. Will wire you whenever supply is obtained.—F. G. Banting

Dr. Morton Ryder, uncle of the twenty-six-pound Teddy, was another whom Banting initially turned away. Trying to offer some hope, Banting suggested that he write to him again in September when there might be some insulin. Ryder replied, “Teddy won’t be alive in September.”

In 1922 there was a fine line between help and harm. Even laying aside the problem of purity, until they were able to achieve a stable potency in the insulin they produced, it was almost impossible to prescribe the right dosage. At Christie Street, several diabetics had suffered hypoglycemic shock as a result of an overdose and had to be revived with glucose. The lack of supply placed diabetic specialists in both countries in grueling dilemmas about which patients would receive insulin, and these decisions had life-and-death consequences. Most doctors agreed that during the experimental stage, only the most severe diabetics should receive insulin. But others argued that if these cases were so frail that the patient would not survive the experiment, shouldn’t they be turned away so that a less desperate case might be given the chance to recover?

Banting turned nearly every case away, yielding only when he was sure that the child was so close to death that the risk of using unstable or impure insulin was justified. He finally accepted three new private patients, three living skeletons from the United States: Myra Blaustein, age eleven, forty pounds; Ruth Whitehill, age seven, forty-three pounds; and Teddy Ryder, age five, twenty-six pounds.

When Mildred Ryder left New York with Teddy for Toronto in early July, a friend helped Mildred with their luggage and waved them off at the station. As the train pulled away, the friend recalled feeling sure that Mildred would never bring Teddy back alive. Mother and son arrived in Toronto on the sleeper on Saturday morning, July 8. They went directly to 160 Bloor Street West. There was no insulin: The last batch had gone inexplicably bad. While Connaught struggled to recover the ability to make effective, nontoxic insulin, the discoverers were dependent upon the Americans for insulin to supply to their own patients. There was nothing to do but wait until Monday when the Lilly shipment would arrive. That Teddy might die within reach of the cure was almost more than Mildred Ryder could bear. To make matters worse, the diabetic clinic at Toronto General Hospital was still a month from opening, and the regular hospital kitchen could not accommodate the diabetic diet, so Mildred Ryder carried poor Teddy through the blistering heat to find a room to rent. She found a suitable situation on Grenville Street, with kitchen privileges so that she could prepare Teddy’s exacting meals herself.

On Sunday Banting took delivery of the first new car he had ever owned. He came by Grenville Street and took Teddy and his mother for a drive in it to lift their spirits. On Monday the shipment from Indianapolis arrived, and Teddy’s recovery began.

Mildred and Teddy liked Banting right away. He was not at all the intimidating celebrity they had expected him to be. He was a plain- spoken man who loved children and had struggled with romance. Often, after giving Teddy his injection, he would linger at the Ryders’ room to confide his troubles to Mrs. Ryder.

Until the diabetic clinic at Toronto General Hospital opened in late August, Banting had been squirreling away his private patients in rented rooms. Several were living at the Athelma Apartments at 78 Grosvenor Street, about a half mile from Banting’s Bloor Street office. In this way he made his daily rounds, walking around the neighborhood from room to room and floor to floor and building to building. Some of these patients and their families became quite friendly with one another. While there was certainly a great deal of hand-wringing, there were occasional light moments too.

Teddy Ryder made a wonderful recovery, but he required up to four insulin injections a day. When he turned six that summer, the Whitehills threw him a costume party at their apartment at the Athelma. Teddy came dressed as an Indian chief with a feather bonnet so long it dusted the floor behind him as he walked around the room greeting everyone.

The last guest to arrive was a tall, mysterious woman in a large white hat, elbow-length white gloves, and a long pink dress. No one knew who she was. When she went to greet the birthday boy, she revealed herself to be none other than Dr. Banting! The room dissolved in torrents of laughter. Teddy Ryder never forgot it.

That summer Banting’s old medical officer from Cambrai called him. Former captain L. C. Palmer asked Banting to see one of his patients—a fifty-seven-year-old woman named Charlotte Clarke. She was a severe diabetic with a badly infected, gangrenous leg whose condition was so poor that she was nearly comatose. At that time, no one had ever survived a diabetic coma. Unable to refuse his old military friend, Banting agreed to see her. The leg had to be amputated, but no one had ever performed surgery on a diabetic, and certainly not one nearly comatose. On the other hand, she was so near death that there was little risk in trying.

Clarke was admitted to Toronto General Hospital, but there was no insulin for her, so five diabetic patients were deprived of their insulin to provide enough to stabilize Clarke. She received her first injection on July 10. Next day, she was wheeled into the operating room and Palmer removed her right leg above the knee. After the surgery her metabolism was kept stable with insulin. Much to everyone’s amazement she began a completely normal recovery. It was the first time that major surgery had been performed on a severe diabetic. Without insulin she would not even have survived the anesthesia.

After about a week, Palmer removed her stitches to reveal an incision that appeared to have healed perfectly. Believing that the insulin had done its work, Clarke received no more insulin after seven days. On July 25, Clarke’s leg became swollen and discolored, and the wound split open to reveal an infection so deep and virulent that Palmer doubted anything could be done to save her, with or without insulin.

Just then, the Connaught insulin production failed again.

Fed up with Connaught’s erratic production, and unable to get a satisfactory explanation from the Toronto chemists, Banting made a frantic trip to Indianapolis to see for himself why the Indianapolis production was working while the Connaught production was failing. He hoped, too, to carry enough insulin back to Toronto to save Charlotte Clarke.

During the journey he fell prey to his old paranoia and began to question why it was that Indianapolis had not experienced nearly so many difficulties as Connaught. Although it was true that Connaught was inexperienced with large stills and equipment to concentrate large volumes, he wondered if the Indianapolis team could have withheld some crucial secret of their process. By the time he arrived in Indianapolis, he was sure he had been betrayed. He determined to demand a complete tour of their facilities and a thorough explanation of their process and refuse to leave until he was satisfied that he had gotten the real story.

He charged off the train in an angry lather, ready to do battle. He was met on the platform by J. K. Lilly, Alec Clowes—and 150 units of insulin. When he was told that he could take it all back with him, Banting was so overcome that he fell onto Lilly’s shoulder and wept. Whether the Toronto team had been too proud or too busy to communicate the dire circumstances in that city, the critical nature of the situation came as a surprise to the Indianapolis team. (It later came to light that Best had communicated the difficulty with the Toronto process to Rhodehamel in Indianapolis, but Clowes had been in Woods Hole and had not seen the correspondence.)

Eli Lilly and Company agreed to delay its own clinical work at Methodist Hospital in Indianapolis in order to supply extra insulin to Toronto until Connaught could recover the ability to make its own. Banting got his tour of the insulin manufacturing plant and process and was dumbfounded by the operations he saw there. He was particularly impressed with the large vacuum still, which was far superior to the antiquated tunnel process that they were using in the basement of the Medical Building, which relied upon evaporation. It was during this trip that Banting confided to Clowes his tribulations with Macleod and his suspicion that he intended to corner the credit for the discovery. Clowes pledged to do whatever he could to protect and assist Banting.

Upon his return to Toronto with the insulin, Banting stopped first at Toronto General Hospital to see Charlotte Clarke. As soon as her injections resumed, Charlotte Clarke’s wound began to heal again. She made a full recovery and lived for many years afterward using a prosthetic leg.

Banting went next to the downtown office of Sir Edmund Walker, chair of the university’s board of governors to procure the money to buy a vacuum still and other equipment necessary to bring Connaught up to the manufacturing standard he had seen in Indianapolis. In his typical combative fashion, Banting marched in and demanded ten thousand dollars immediately. Walker coolly assured Banting that he would raise the issue at the next board of governors meeting in the fall. Knowing that such a delay would cost lives, Banting was outraged by what he saw as a smug bureaucratic attitude. He asked Walker if the board of governors would accept the money if Banting could get it for them. Walker agreed. Banting stormed out.

Next day he was in New York with Dr. Rawle Geyelin, one of the original recipients of insulin and a member of Toronto’s Insulin Committee. Banting watched in awe as Geyelin picked up the phone and called Robert Bacon, the wealthy parent of a diabetic child. Geyelin briefly explained the situation, then turned to Banting and asked how the check should be made out. Banting had a check for the full amount that day, and Toronto got its vacuum still.

Geyelin was appalled to see the discoverer of insulin begging for money. He told Banting that if he moved to New York he could make one hundred thousand dollars a year without any difficulty. Geyelin was amazed to learn that Banting had charged only a hundred dollars to Charlotte Clarke and twenty-five dollars a week to his insulin-dependent patients in Toronto. That summer Frederick Allen offered him a job at the Physiatric Institute, and according to Banting, an American investor offered him a million dollars for the rights to insulin.

On July 26, J. K. Lilly wrote directly to Banting.

We were sorry that you found it necessary to hurry off so quickly after our very pleasant visit from you, yet we appreciate the necessity of your returning, and were very happy indeed that we were able to have you return with 150 units of insulin. Appreciating, Doctor, that Mr. Scott may not get into production until well into August, we have arranged a program that will enable us to increase our production in such a manner that we believe that we can supply you 500 units per week during the month of August. We sent another 150 units by Mr. Scott, and will use our utmost to get to you promptly each week in probably two or three shipments 500 cc’s. We trust this will be of substantial assistance to you. We are having apparatus constructed to enable the large scale production. . . . Working as quickly as possible.

On July 29, Lilly sent 200 units of insulin to Toronto. On August 8 they sent 500 units and pledged to try to continue to send 500 units per week. Canada’s entire production of insulin depended on Connaught, and Connaught depended on Charley Best. At twenty-three years of age, Charley Best was now responsible not only for directing Connaught’s insulin production but also for working with Lilly on standardization and stabilization.

The question of who should be the first American given the first injection of Lilly insulin was resolved by J. K. Lilly Sr. He decided that Dr. Elliott Joslin, who had devoted so much of his life to the care and study of diabetics, should have the honor of giving the first American preparation of insulin in an American institution by an American doctor to an American patient. (Dr. Woodyatt in Chicago was the first American physician to use insulin on a human patient, but the extract came from Toronto.) Miss Elizabeth Mudge, a nurse with (Type 1) diabetes, was forty-one years old and had no hope of seeing forty-two when Joslin chose her as the most desperate case to receive insulin. She weighed 69 pounds on August 7, 1922, and was in a near coma when she arrived at Boston’s Deaconness Hospital by ambulance. So dire was her condition that Dr. Howard Root, a colleague of Dr. Joslin who happened to meet the ambulance, recognized immediately that there was no time to lose. With the ambulance still idling in the street outside the hospital, Root injected Mudge with two units of insulin while she lay moribund on the stretcher, pushing the needle through the blanket in which she was wrapped. She made a full recovery.

Hearing this news, Charley Best could not help but think of his favorite aunt. Among the thousand or so names recorded in Dr. Joslin’s registry was the name of Helen Best. She was a nurse in her thirties when she went to see Dr. Joslin in February 1915 to seek help for her diabetes. At the time all Joslin could do for her was to prescribe the Allen diet. As a nurse, Helen well understood the seriousness of her disease and the importance of absolute compliance with the dietary regimen. Despite her strict observance, she died in a diabetic coma in May 1917.

* * *

In early August, Dr . Allen traveled to Toronto. There he met Teddy Ryder—not the Teddy Ryder he had treated at the Physiatric Institute, but an entirely different boy with the same name. The new Teddy was a vigorously healthy, happy boy with a round face and a thick mop of brown hair. For the first time in his life the voluble Dr. Allen was struck dumb. When he returned to the institute in Morristown, he stood humbly before his gaunt charges and said quietly, “I think I may have something for you.”

Throughout the summer of 1922, the insulin plant at Lilly had been running three shifts. The lights never went out in the Science Building. Over one hundred workers focused solely on the problem of large-scale production of insulin. By August, Walden and his team had been able to increase the yield to roughly one hundred units per pound of pancreas. Kingan (and Billy Sylvester) could not meet the demand at Lilly. The first shipment of frozen pancreas glands by refrigerated railroad car was arranged with Swift and Company of Chicago.

Now Indianapolis began to experience the problems with potency that Connaught had experienced. Although Lilly had succeeded in increasing scale and yield, the potency of the final product decreased by as much as half. Thus in order to meet the agreed-upon shipments of insulin to Toronto and to the sixteen clinicians, production had to be doubled. The stress on George Walden, Harley Rhodehamel, and Jasper Scott was overwhelming. While Lilly was making every effort to help Toronto with their crisis, the unintended result was to create a second crisis in Indianapolis.

In August 1922 Walden was near nervous collapse. In order to forestall a complete breakdown, Clowes insisted that he join him in Woods Hole for a two-week rest. However, while Clowes had narrowly averted one nervous breakdown, Jasper Scott, who had been assigned Walden’s responsibilities in his absence, did suffer a breakdown. This required his taking a rehabilitative rest of three weeks.

Clowes now received a telegram from Lilly in Indianapolis informing him that production had fallen below expectations, and if they were to continue to send Banting five hundred units per week, they would be unable to supply Woodyatt, Geyelin, or Wilder at the Mayo group. On August 8, he sent a telegram to Banting, asking if he could reduce dosages and work with three hundred to four hundred units per week instead of the usual five hundred.

In August 1922, the quality, quantity, and potency of each batch were utterly unpredictable, and deterioration and sensitization reactions continued to present problems for clinical use. Clinical data from all of the participating physicians accrued and was analyzed in Toronto: There was a frustrating mixture of miraculous recoveries and baffling failures. Both Williams of Rochester and Woodyatt of Chicago had patients who died of hypoglycemic shock after receiving an overdose of insulin. Some parents of children who had endured the Allen treatment were desperate enough to be fearless. One eight-year-old boy, too weak to stand, was carried in to Joslin’s office by his parents, who reportedly told the doctor, “Do anything you want with Frederick, you can’t make him any worse.” The human trials at Banting’s clinic at the Christie Street Military Hospital had been discouraging. Stories about painful abscesses and hypoglycemic reactions deterred many diabetic veterans from participating in the program. Even Joe Gilchrist, who was promoting the program, suffered a dramatic hypoglycemic reaction. But then Banting decided to teach participants to administer insulin themselves so that they could take leave of the hospital on the weekend, and interest picked up. Interest increased even more when the first few men returned from weekend leave to report that insulin had a restorative effect on both their libido and their performance.

On August 10 Allen injected six patients with Lilly’s insulin. Had Elizabeth been in Morristown she certainly would have been among them. In order to distribute the supply to the most recipients—and for fear of hypoglycemic reaction—he gave each less than one unit. The results were dramatic. Patients were restored to vigor so quickly that the results were sometimes referred to as resurrections. Blanche took Elizabeth to Morristown to await the next shipment of insulin. Antoinette wrote another letter to Dr. Banting, again urging him to accept Elizabeth as his private patient. And then she did something she had never done before, something that she had sworn she would never, ever do. She asked her husband to intervene.