Episode 9: The Insulin Famine

“Elizabeth Hughes: Living with Insulin”

By Christopher J. Rutty, Ph.D

Lead Historian, Defining Moments Canada “Insulin 100” Project.

Prominent in the featured podcast episode, “The Insulin Famine,” is the story of Elizabeth Hughes, the 15-year-old daughter of the U.S. Secretary of State, Charles Hughes, whose life was saved when she came to Toronto for insulin treatment from Dr. Banting. Elizabeth was certainly privileged in getting the opportunity to receive the treatment, but Banting accepted her as a patient primarily because of her severe diabetic condition, and because she had the support of a private nurse, Blanche Burgess, who was well educated in managing Elizabeth’s strict diet. Blanche’s support, coupled with Elizabeth’s diligence as a “student of diabetes,” provided Banting and the rest of the Toronto group with a unique opportunity for the clinical evaluation of insulin at a critical point in its development and production.

Further details about Elizabeth’s experience in Toronto from mid-August until the end of November 1922, are discussed in an article elsewhere on this site.[1] One is left wondering what happened to Elizabeth after she left Toronto. Based principally on the book by Caroline Cox, The Fight to Survive: A Young Girl, Diabetes, and the Discovery of Insulin, published in 2009, along with several other sources, this installment highlights the course of Elizabeth’s life with insulin.

On December 1, 1922, Elizabeth boarded a train in Toronto bound for her home in Washington, D.C., determined to be an independent, though insulin-dependent, young woman. She would be “Captain of my own ship,” as she put it. Elizabeth had emerged from a terrible nightmare during her three-and-a-half months in Toronto, restored and transformed by daily insulin treatments, as well as a carefully managed diet. She was Banting’s iconic insulin-managed diabetic patient. Elizabeth was first diagnosed with diabetes in 1919 and had survived on the Allen “starvation” diet longer than most, thanks to her own determination, as her many letters attest, and Blanche’s diabetic nursing support. Still, her decline to death seemed inevitable and accelerating by July, 1922, when she arrived home from Bermuda weighing just 21.8 kg. The contrast in Elizabeth five months later, when she arrived home from Toronto, could not have been more dramatic.

Not long after reuniting with her family and friends, Elizabeth said goodbye to Blanche, who was engaged to be married to Dr. McClintock, whom she had met in Toronto. The couple planned to move to California. Blanche had been with Elizabeth for three years and had played a huge role in keeping her alive and independent. Despite that, they never saw each other again. Blanche, however, was a reminder for Elizabeth of the nightmare she had endured, and their parting was symbolic of Elizabeth’s determination to move on. Indeed, as was clear in a formal photo published in the Washington Post in March, 1923, Elizabeth had returned to society and was available for tennis parties, horseback-riding competitions and concert invitations.

Nevertheless, Elizabeth could never forget her diabetes, nor her twice-daily insulin injections, nor her careful diet management. Through her father’s office, an arrangement had been made with Banting for regular monthly shipments from Toronto of Connaught Laboratories’ insulin (known as “Insulin-Toronto”), initially of 1,200 to 2,000 units, until the end of 1924. During 1925, insulin shipments from Toronto became bi-monthly and larger, usually 4,000 units each through 1926 and into 1927. There were sometimes larger shipments to cover periods when Elizabeth travelled with her parents. She maintained her preference for Connaught’s insulin at least to the spring of 1927, which is as far as Connaught’s insulin sales records have been examined.[2] There was little reason to change to another type of insulin produced in the U.S., although at some point, she likely did.

Her insulin supply remained stable and consistent, and gradually fell in price: in January 1924, 1,200 units cost $24; a year later, 2,000 units cost $18. By April, 1927, 4,000 units cost $28. However, Elizabeth encountered several struggles, including “unsettling changes in her body,” particularly weight gain. She worried, as she told Banting in early 1924, that she “did not seem to be growing and developing in accord with my age.” In January, 1923, she weighed 38 kg (nearly double her weight from the previous summer), and two weeks later reached 41.73 kg. By early 1924, she reached 46.72 kg.

Her new body felt strange. She told Banting she was trying to get some strenuous exercise each day to work off some of the calories and prevent gaining more weight, focusing on swimming and horseback riding. Her weight soon fell to 41.7 kg, but Elizabeth felt it was time to reduce her diet. “I don’t want to gain so very fast the way I was doing,” she wrote, “and yet I don’t want to lose any so I hope I can strike a happy medium in this way.” Elizabeth’s struggles to balance her diet with her insulin and exercise while maintaining a stable weight were certainly common among the first generation of insulin-dependent diabetics, particularly given the variations in insulin potency and quality.

Despite her best efforts, Elizabeth’s delicate balancing act suffered a severe setback during the summer of 1924. She was staying with her sister in New York City while her parents were away. As was reported in the press on August 9^th, she had “chronic diabetes” and “suffered a severe recurrence Wednesday afternoon while playing tennis with a friend.” Elizabeth was admitted into Dr. Allen’s sanitarium in Morriston, N.J., where she stayed for a month to recover. By September, she was able to return home. After this experience, and the ensuing media attention, Elizabeth became increasingly determined to put her personal nightmare behind her.

Two developments during 1925 helped in this process. Elizabeth’s father retired from public life and was able to spend more time with her. As well, Elizabeth graduated from high school and was free to spend time away before the family completed its move from Washington to New York City. She worked for her father in his law office, helping him keep up with correspondence and other secretarial tasks. Elizabeth was also accepted into Barnard’s Women’s College at Columbia University. It was during this period that Elizabeth and her parents “agreed to forget diabetes with her.” There would be no public reference to it.

Nevertheless, Elizabeth’s struggles to find a comfortable weight continued during her first year of college. She was especially unhappy when her weight shot up to 71.66 kgs, which she felt was too much for her 5-foot-2-inch frame. She managed to make some diet adjustments and lost about 9 kg. By the time Elizabeth graduated in 1929, she had settled into a daily routine that balanced diet, exercise and insulin injections. She maintained this routine for the rest of her life.

Soon after graduating, a young lawyer Elizabeth met in her father’s law firm, William T. Gossett, proposed. However, before she could accept, Elizabeth faced a dilemma: she had not told Bill about her diabetes. Elizabeth did not want to revisit her nightmare, and she also knew that diabetic women were usually unable to carry pregnancies to term (since the introduction of insulin, some had). Elizabeth’s mother encouraged her to have the critical discussion with Bill. The next evening, Elizabeth and Bill discussed her condition. She need not have worried: the wedding was still on. In December, 1930, the child who had been near death eight years earlier, had become a healthy, happy bride. She would soon be the mother of three children, each delivered by Cesarean section.

In her new life, Elizabeth remained determined to keep her childhood nightmare of diabetes and starvation, as well as its happy outcome, not only away out of public view, but away from her own children as well, or at least until they were adults. If anyone broached the subject, she said the disease had afflicted her younger sister, Helen, who died in 1920. Of more concern to her father was the attention of reporters and biographers. Elizabeth’s mother died in 1945 and her father passed away in 1948. The men in the family (her brother, brother-in-law, and husband) served as executors of the Hughes estate, but Elizabeth was given the opportunity to go through her father’s papers before they were given to the Library of Congress. As she went through the files, Elizabeth removed anything that mentioned her diabetes and destroyed all photos of herself taken during her pre-insulin nightmare. She did not want that part of her life to be a matter of public record while she was alive.

By 1980, when Elizabeth was in her early 70s, her perspective on her diabetes and 58 years of insulin use had broadened. She realized her story might hold meaning for others. Historian, Michael Bliss, while researching The Discovery of Insulin, tracked down Elizabeth in 1980, and she agreed to an interview. Yet, she first had a question for Bliss: what ever happened to Dr. Banting? Elizabeth and Banting’s last correspondence was during her second year of college, in about 1926. She had told him how wonderful she felt and how happy she was in her work. “So you see,” she told him, “I have nothing to complain of.” Bliss brought her up to date about Banting’s life, work and tragic death in a plane crash in 1941. While Elizabeth had kept herself informed about the latest developments with diabetes management, she confessed to Bliss that she’d severed all connection to her nightmare of starvation therapy. Even thinking about the scale that she and Blanche used in order to weigh every crumb of food drove her crazy. Through her married life, Elizabeth had maintained disciplined eating habits, which included regular mealtimes, as well as a strict daily exercise routine. She had two insulin injections each day, one as part of her morning routine, and the other at 5:00 pm, when she could close the door.

Elizabeth Hughes died on April 21, 1981. She had given permission that her story could be made public after her death. The timing of her interview with Bliss was fortuitous. Elizabeth had been afraid that if others knew of her diabetes, they would have made a fuss, offered unsolicited advice and asked probing questions. She had kept her personal diabetes story to herself through most of her life. But she was rarely bitter about her illness. Like her parents, and her husband, Elizabeth was civic minded. She felt it was important for her to use her example and legacy to good use. Elizabeth was also compassionate and had no desire to control her diabetes story after her death. Her spirit of generosity provided a unique and important window into the transformative impact of insulin on one person, and allowed other diabetics, and the public in general, to better understand its impact.

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[1] See the article, “Elizabeth Hughes: Letters From Toronto,” https://definingmomentscanada.ca/elizabeth-hughes-letters-from-toronto/

[2] See the article, “Tracing the Spread of Insulin,” https://definingmomentscanada.ca/tracing-the-spread-of-insulin/

Dr. John G. FitzGerald: Friend, Facilitator and “Fifth Beatle”

By Christopher J. Rutty, Ph.D

Lead Historian, Defining Moments Canada “Insulin 100” Project.

Early in “The Insulin Famine” podcast episode, it is noted that Dr. John Gerald FitzGerald was a close friend to Frederick Banting. The founder and director of the University of Toronto’s Connaught Antitoxin Laboratories, FitzGerald played an essential role in making an insulin supply possible, practical, effective and accessible to diabetics in Canada and globally.[1] Indeed, if one were to extend the idea of a “Fifth Beatle” to the insulin story,[2] FitzGerald would certainly fit that role. As Charles Best said of his mentor, “There would have been no insulin without FitzGerald.”[3]

However, FitzGerald’s role in the insulin story went beyond making possible its original development and production. He served as a facilitator on many levels and offered friendship and support to all members of the Toronto discovery team, especially Banting and Best. He was critical to holding the team together.

As the 2010 memoir by James FitzGerald, What Disturbs Our Blood: A Son’s Quest to Redeem the Past, recounts,[4] John Gerald FitzGerald (1882-1940) was the son of a pharmacist, one of the University of Toronto’s youngest medical school graduates, and a fiery redhead who grew increasingly determined to bring the benefits of essential public health products (antitoxins, vaccines, and later insulin) within the reach of everyone. Prior to the establishment of Connaught (originally known as the Antitoxin Laboratory) at the University of Toronto in 1914, such essential public health products were not produced in Canada, and therefore had to be imported, often at prices that put them out of reach of families most vulnerable to diseases such as diphtheria. Founded by FitzGerald as a self-supporting lab based in the university’s Medical Building,[5] Connaught quickly expanded to meet this public health need in Canada and soon was able to export, initially to help support British military needs for tetanus antitoxin and smallpox vaccine during World War I.

During the summer of 1921, while walking the halls of the Medical Building, FitzGerald likely heard the sound of barking dogs coming from the lab where Banting and Best were working on their initial pancreatic extract experiments with diabetic dogs. FitzGerald and Banting likely met at some point during the summer. By the fall, they had talked about the progress of the work. Banting also told FitzGerald about the personal, practical and financial frustrations he felt, particularly with Professor J.J.R. Macleod’s limited supports, that led him to consider taking the research elsewhere. FitzGerald advised Banting not to leave Toronto without consulting him first, and he soon helped facilitate better support. In late January, 1922, after Banting and Dr. J.B. Collip almost came to blows when Collip threatened to return to Alberta and take out his own patent following the first successful test of the more purified extract he had prepared, FitzGerald stepped in as peacemaker. Fearing the loss of the work just as the extract had proven effective in a human diabetic, FitzGerald facilitated a seminal agreement between Connaught and Banting, Best, Collip and Macleod to work together to develop larger scale methods for producing the extract for further clinical trials.[6]

Even before this agreement was in place, FitzGerald was working closely with Best, hiring him as Connaught’s director of extract production, a role that provided Best with a salary and enabled him to complete a master’s thesis project focused on physiological studies of the extract. In early May, 1922, Best became Director of Connaught’s Insulin Division and also managed the insulin development partnership with Eli Lilly. Best increasingly regarded FitzGerald as a mentor, supporting his progress through medical school while he directed Connaught’s insulin production.

On October 26, 1923, when Banting first heard the news of his winning the Nobel Prize, and his immediate negative reaction when he learned he had co-won the Prize with Macleod, FitzGerald was the first person to hear how upset he was. Banting told FitzGerald he couldn’t accept the award. After letting Banting vent his anger, FitzGerald was able to calm him down and get him to discuss the matter with Albert E. Gooderham, chair of the University of Toronto Insulin Committee, who Banting saw as a father figure. Although Gooderham was able to calm Banting down and advise him to take the first boat to Stockholm, Sweden, to claim the Nobel Prize in person, Banting resisted considering such a trip until 1924 when FitzGerald urged him to go. During the summer of 1925, FitzGerald had also spent more time with Banting, encouraging him to patch things up with Collip (which he did the following summer), and to finally make the trip to Stockholm to formally accept his Nobel Prize and deliver the customary Nobel Lecture. Banting invited FitzGerald to attend the Nobel ceremony after travelling together. FitzGerald had already made plans to visit several labs in Europe on behalf of Connaught, and so could include a stop to listen to Banting accept the award on September 15, 1925.

Meanwhile, in 1924, FitzGerald appointed Best to be an assistant director of Connaught and he also helped arrange for him to secure a Rockefeller Foundation fellowship to support his postgraduate studies in England and Europe after graduating. Best left on his 18-month fellowship on July 9, 1925; by the time he returned to Toronto, FitzGerald had secured a position for him as Head of the Department of Physiological Hygiene in the new School of Hygiene. In June 1927, the School officially opened in a new “Hygiene Building” that also served as Connaught’s headquarters and included expanded insulin production facilities. After the School’s opening ceremonies, FitzGerald, Best and Banting led a tour of the new building.[7]

By the 1930s, FitzGerald was working closely with Best through his direct involvement with Connaught and the School of Hygiene, but less so with Banting, who was based in the Banting Institute as Chair of the Banting and Best Department of Medical Research. FitzGerald was closely involved with the development of the Banting Research Foundation, although Banting’s own research work post-insulin and into the 1930s had become a mostly frustrating experience, prompting him to seek satisfaction in exploring his artistic interests.[8]

By the late 1930s, FitzGerald and Best’s relationship became more personal, especially as FitzGerald suffered from increasingly severe bouts of depression that had forced him to take an extended medical leave. Best provided support to FitzGerald during this period in many ways, including spending time at the Connaught Farm site, where FitzGerald lived. Best was an avid horseback rider and enjoyed his visits to the Connaught Farm. Best also had seen depression in his own family and would later be afflicted himself.[9] For FitzGerald, his psychological decline worsened during 1939 and into 1940, leading to two suicide attempts, and succeeding with the second one on June 20, 1940.

Banting and Best were among the pallbearers at FitzGerald’s funeral, which drew hundreds of mourners from the Canadian and international medical elite. The funeral took place in the University of Toronto’s Convocation Hall, just metres west of the Medical Building in which insulin had been discovered and developed. However, there was no public mention of suicide; the given cause of death was a duodenal ulcer. FitzGerald’s death occurred amidst the worsening crisis of World War II, with the relentless bad news of German advances. On the day of FitzGerald’s funeral, Banting wrote in his diary: “This has been the worst week imaginable.”

Banting died in a plane crash not quite eight months later, prompting rumours of wartime espionage and sabotage. But FitzGerald’s death remained shrouded in silence. Details of his suicide wouldn’t surface for more than six decades, until his grandson, James FitzGerald, published his memoir, What Disturbs Our Blood. However, the shroud that similarly obscured FitzGerald’s vital role in the insulin story began to lift in 1982 with the publication of Michael Bliss’ book, The Discovery of Insulin.

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[1] See the article, “History of Connaught” and most of the others that follow here, https://definingmomentscanada.ca/insulin100/article-list/

[2] https://en.wikipedia.org/wiki/Fifth_Beatle

[3] James FitzGerald, What Disturbs Our Blood: A Son’s Quest to Redeem the Past (Toronto: Random House, 2010), p. 386.

[4] https://www.jamesfitzgerald.ca/what-disturbs-our-blood

[5] The story of the University of Toronto Medical Building is told in a feature article associated with the “Eureka” episode of The Life and Times of Sir Frederick Banting podcast, https://definingmomentscanada.ca/episodes-4-and-5-freds-idea-and-eureka/

[6] See the article, “It Works! Now What?”, https://definingmomentscanada.ca/insulin100/timeline/it-works-now-what/

[7] See the articles in “The Lasting Legacy of Insulin” series, particularly, “Insulin Research & Innovation Legacies: The Best in Biotechnology,” and “Profiles, Before and After Insulin: Charles Herbert Best,” here, https://definingmomentscanada.ca/insulin100/historicstories-discoveryresearch/

[8] https://definingmomentscanada.ca/insulin100/banting-story-map/

[9] https://definingmomentscanada.ca/profiles-before-and-after-insulin-charles-herbert-best-1899-1978/