Author: Michael Bliss

With a mission ‘to reconstruct the insulin research dog by dog, day by day, experiment by experiment’, this book is a detailed and forensic portrayal of the history of the discovery of an extremely vital hormone. Referring to the insulin story as ‘one of the most dramatic events in the history of treatment of disease’, and as ‘one of the genuine miracles of modern medicine’, the book documents a tale that the author said is ‘a much more intricate, complex event than our conventional accounts have suggested’. Indeed this account, as fascinating as it is surprising, not only criticised the research carried out by Frederick Banting and Charles Best, it also gives greater credit to John MacLeod and James Collip – the lesser appreciated heroes of the insulin saga. As the author chronicled the convoluted journey towards the discovery of insulin, arguing that this was ‘not a model of how medical research would develop’, he also highlights the profound impact the discovery had on medicine, saying ‘with insulin, the stone was rolled away and diabetes became a matter of the quality of life, not the speed of death’ (pages 11, 17, 19, 245 and 248).

Frederick Banting is unarguably the person who is most notably associated with the discovery of insulin, and indeed this book credits him for the idea and the driving force behind the project. After an undistinguished and unsuccessful career in private practice and research, the author traced Banting’s original insight to 1920 when he read an article about the relationship of the pancreatic islet cells with diabetes – an experience that started him ‘thinking about the problem of the internal secretion‘. The book also described how he wrote down ‘an idea for an experimental procedure‘ – to ligate the pancreatic duct and extract the secretion from the degenerated part of the gland. The narrative also documented how Banting met John MacLeod, already a leading researcher, and how, with research assistant Charles Best, they set out to extract degenerated pancreatic tissue secretions and see the effect on diabetic dogs. The book particularly emphasised the  frustrating and almost uniformly unsuccessful early dog pancreatectomy operations carried out by Banting and Best, the author describing this challenging period as ‘an unforgettable time in the lives of the young scientists’ (pages 12, 45-52,59-65 and 67-75).

An astonishing feature of this book’s account of the research carried out by Banting and Best is its characterisation of their work as sloppy and disorganised, the reason being that they ‘missed opportunities…to plan a rational course of experiments’. For example, the author argued that, contrary to the evidence of their own experiments, they stuck to the ‘faulty hypothesis‘ that ‘it was necessary to do something to a pancreas to get rid of the external secretion‘, or that ‘a degenerated gland was necessary to produce potent extract’. The author went further to criticise Banting for ‘his relative disinterest in medical scholarship, his weak background knowledge, and his inexperience at research’, explaining that these shortcomings ‘militated against a careful, thorough study of the literature‘. In explaining why this substandard quality of the research carried out by Banting and Best was not well known, the author referred to the prevalent view ‘in medical and historical circles’ that ‘critical discussion of Banting and Best’s work amounted to belittlement of a great achievement‘. Contrary to ‘the judgment of history’ that the two were ‘the discoverers of insulin’, the author portrayed them as ‘two inexperienced researchers in a city and a country which has no particular stature in the world of medical research‘ (pages 13-14, 77 and 85-88).

Unlike the more widely known history that the discovery of insulin was solely the outcome of research carried out of Banting and Best, the picture this book painted was that it was ‘a collaborative process, drawing on the talents of at least four people‘. In a heavily evidence-based narrative, the book highlighted the decision of the Nobel Committee to give its 1923 prize to Banting and MacLeod, the author arguing that unlike Banting, MacLeod was already ‘a competent researcher and prolific writer and synthesizer of current knowledge in physiology’, and that he had already been investigating internal pancreatic secretions. Unlike Banting, who the book depicted as ‘an intensely direct man, quick to anger, ready to fight anyone on any matter of principle’, the author portrayed MacLeod as a calm and wise voice, and a guide who frequently redirected the research direction of Banting and Best. The author nevertheless acknowledged that McLeod’s ‘attitude’ to the work was ‘a bit obscure‘ at the beginning, ‘giving them advice and help‘ but ‘not actively directing them’ or adding to their ‘resources‘. The author therefore concluded that ‘on their own, Banting and Best were not experienced and knowledgeable enough to have carried the work through to a successful conclusion‘ without Macleod’s contribution. Similar to his positive view of MacLeod, the author also credited James Collip for having ‘far more experience at medical research than Banting’, and he supported this by citing Collip’s singular role in developing the pancreatic extract that was fundamental to the discovery of insulin (pages 8, 32-33, 82, 89-103, 117-120 and 208-209).

To complement its detailed depiction of the discovery of insulin, the book also documented an exhaustive account of the history of diabetes which covered the diverse facets of the devastating disease. For example, in narrating the evolution of the understanding of its pathology, the book referred to the mid-nineteenth century autopsy studies which demonstrated pancreatic damage in some cases; the finding, by Paul Langerhans, of the two pancreatic cell systems – the acini and islets; the ‘great experimental breakthrough’ of Oskar Minkowski who created a diabetes-like state by removing the pancreas of a dog; and the demonstration by Eugene Opie in 1901 of ‘a pathological connection between diabetes and damage to the mysterious’ islet cells. The author also charted the emergence of ‘techniques for measuring blood sugar‘ by Israel Kleiner, referring to this as one of the most important developments in diabetes research. And in its account of the transformation of its treatment over the centuries, the book described how the disease was treated in the mid-nineteenth century by ‘bleeding and blistering and doping‘ with opium, and how, even in the beginning of the twentieth century, some people thought that the cure rested in increasing sugar consumption. And in crediting the ‘first important advance‘ in the treatment of diabetes, the author referred to the work of Frederick Allen – ‘a stern cold, tireless scientist utterly convinced of the validity of his…total dietary approach‘ (pages 23-41).

This forensic account of one of the most dramatic episodes in the history of medicine turns out to be a complex tale of the march of scientific – the development of an idea, its germination and modification, the gruelling experiments and the collaboration that underlie its success. It is also replete with the lessons of the errors that can derail progress; false paradigms that stifle innovation, the need to question received wisdom and assumptions, and the rivalries that can mar the work. The retelling is skilfully clear, and the assertions seemingly irreproachable. The book has served am important role in setting the records of the individual contributions of each pioneer, at the same time demonstrating the requirement of diversity for any effort to achieve its objectives.

This book is not only a history of a seminal discovery, it is a multifaceted biography of the pioneers who made it. The importance of insulin to medicine cannot be overstated, and the awe is only heightened by the revelation in this book of the background work that enabled its discovery. Whilst the hard work and eventual outcome evoke inspiration, the book also cautions about the traps that hinder scientific advances. The story this book tells is critical to both the clinical and the research aspects of healthcare, and I recommend it to all doctors.

Publisher, Place, Year: University of Chicago Press, Chicago, 1982

Number of chapters: 10

Number of pages: 304

ISBN: 978-0-226-05899-3

Star rating: 5

Price: £36.98