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Home , Bernardo Houssay, Frederick Banting, William Osler

Reviews/Commentaries/Position Statements PRESIDENTIAL ADDRESS

2002 Presidential Address: A Tide in the Affairs of

There is a tide in the affairs of men ment, very little progress was made in sity, and University, where he was Which taken at the flood, leads on to fortune; treating . It is fair to say that al- knighted and was the Regius Professor of Omitted, all the voyage of their life most everything we now know about its Medicine. Osler was, and remains, the Is bound in shallows and in miseries. causes and treatment has been learned most revered of all clinicians and the —Shakespeare, Julius Caesar, act iv, scene 3 just over the last hundred years or so. quintessential academic , idol- What, then, was understood, and ized not only in his time but ever since, am convinced that at this moment, we what was done about diabetes just 100 particularly at Johns Hopkins. are riding a great tide of scientific years ago, in 1902? The answer, quite What did Osler do to treat diabetes on progress. There are opportunities that simply, is not much, particularly in the the wards? He did use medical nutrition I realm of therapeutics. Through the last have never existed in the history of hu- therapy, prescribing a “von Noorden” diet mankind—opportunities to advance our half of the 19th century, the best minds in that contained 65% fat, 32% protein, and understanding of diabetes and its treat- medicine were most busy naming dis- 3% carbohydrate. In his famous textbook ment, opportunities even to cure diabe- eases, classifying them, describing their of medicine (6), Osler also carefully pre- tes. The American Diabetes Association natural history and prognosis. Some star- scribed “20 cc whiskey in 400 cc water” (ADA), our community of scientists and tling advances were made, such as the dis- with black coffee for lunch. But in the clinicians throughout the world, and so- covery of bacteria as pathogenic, the end, his therapy was nonspecific at best. ciety as a whole must seize these oppor- importance of antisepsis, anesthesia, and His discussion of treating diabetes con- tunities, or all our lives will, indeed, be vaccination. And the description of diabe- cluded with the depressing thought that bound in the shallows and miseries of un- tes was being refined, with a hint at the “opium alone stands the test of experience fulfilled possibility. distinction between what we now call as a remedy capable of limiting the I would propose that we have reached type 1 and type 2: progress of the disease” (7). this moment of scientific opportunity in a The most prominent clinical feature of dia- So 100 years ago, medical therapeu- relatively short period of time, about 100 betes is the manifold differences that exist tics was on the whole a mixed bag of years, and that the credit for progress over between different cases of the disease, so polypharmacy, home remedies, crude this past century is due more to the pains- that the conclusion is reached that these dis- surgery, and pain management. The age taking work of many scientists and clini- tinct types of the disease must have dissim- of scientifically proven therapeutics, of cians than to the triumphs of a few ilar pathological basis.... evidence-based medicine, had simply not brilliant discoveries. arrived. Diabetes itself, of course, has been . . . It has always been debatable whether Throughout the later 19th century recognized for a long, long time—at least mild forms of diabetes ever progressed so as to become severe forms. (3) and into the early 20th, however, the sci- 3,500 years. The ancient Egyptians knew entific tide was beginning to gather. No- it very well, as documented in the so- On the whole, 100 years where was this better illustrated than in called Ebers Papyrus (1). Fifteen hundred ago were confined to making a diagnosis the events leading to the first therapeutic years later, Aretaeus (130–200 CE) not and a prognosis and providing pain relief use of in 1921. Indeed, while the only used the term diabetes (from the and human comfort. There was very little “discovery of insulin” in was an Greek for siphon), but accurately de- specific therapy available. In 1913, the enormous therapeutic advance, it is a mis- scribed the signs and symptoms: most famous diabetes expert at the time, take, in my view, to consider it a miracle, Frederick Allen, agreed with Josef von a stroke of genius. Bliss’s classic book, The It is a dreadful affliction, not very frequent Discovery of Insulin (8), describes the se- among men, being a melting down of the Mering’s opinion that he had “never seen flesh and limbs into urine. The patient a genuinely cured diabetic” (4). This era ries of steps that led up to the use of insu- never stops making water, and the flow is of medicine is beautifully described in a lin, occurring over the prior 50 years or incessant, like the opening of aqueducts. (2) new biography by Professor , so. : A Life in Medicine (5). Osler In 1869, Paul Langerhans, a German Several millennia passed without sig- was the preeminent clinician and physi- medical student, had used the newly im- nificant progress in the understanding or cian of the late 19th and early 20th cen- proved microscope to note the clusters of management of diabetes. Through the en- turies. He was international—born, cells that would bear his name, but the tire span of human history, in fact, from raised, and educated in Canada; trained in “ of the cells, author (Langerhans) ancient Egypt, the Greek and Roman em- the best clinics in Europe; and holding confesse[d] himself ignorant completely” pires, through the dark ages, middle ages, major teaching positions at the University (9). They were cells without known pur- and the Asian dynasties, even through the of Toronto, the University of Pennsylva- pose, like the many genes without known Renaissance and the Age of Enlighten- nia, the nascent Johns Hopkins Univer- purpose today.

520 DIABETES CARE, VOLUME 26, NUMBER 2, FEBRUARY 2003 Presidential Address

In 1889, 20 years after Langerhans’ From 1902 on, the scientific issue be- “The Idea.” Preparing for a lecture on di- descriptions of the mysterious islets, a re- came how to successfully isolate this sub- abetes to a small medical school in Lon- nowned professor in Strasbourg, Oskar stance from the islets and how to use it to don, , Banting browsed the Minkowski, was studying digestion. On a treat diabetes. There is no doubt that the current edition of Surgery, Gynecology and challenge from Josef von Mering, goal was to find a treatment for diabetes. Obstetrics, which had a relevant article de- Minkowski demonstrated that he could To quote from another passage from that scribing the ligation of pancreatic ducts perform a surgical pancreatectomy in a time reprinted recently in the Journal of (16). A photomicrograph showed preser- dog. As described by the Argentinean No- the American Medical Association: “And it vation of the islets of Langerhans as the bel Laureate (10), may not be too far-fetched to suggest that pancreatic acinar tissue degenerated. Minkowski’s animal caretaker found that eventually some form of organotherapy of Banting thought this procedure could be the dog had become uncontrollably poly- diabetes may develop. . . ” (3). used to isolate the contents of the islets: uric and polydipsic. Minkowski, after So I am asserting that the advances thoroughly scolding the poor man for not were steady, inexorable, with a series of Oct 30/1920. Diabetus [sic]: Ligate pancre- cleaning the cages, realized that these contributors. The tide was on the rise. atic ducts of the dog. Keep dogs alive till were symptoms of diabetes and proved it In The Discovery of Insulin (14), Bliss acini degenerate leaving islets. Try to isolate by demonstrating in the urine. He summarizes the work of other scientists internal secretion of these and relieve gly- proceeded to confirm that pancreatec- who were also extracting insulin even be- cosurea [sic]. (17) tomy causes diabetes and rightly con- fore the Toronto group: Georg Ludwig cluded that there is some necessary Zuelzer in Berlin in 1906; E.L. Scott at the It was a startling idea, with all the antidiabetic factor in the . He had University of Chicago in 1911–1912; Is- hallmarks of genius, especially, I expect, no idea what it was within the pancreas rael Kleiner at the Rockefeller University to Banting, who was not trained in science that protects against diabetes. in 1919; and of course Nicolas Paulesco, and had little up-to-date understanding Enter a young pathologist, Eugene professor of in the Romanian of diabetes. So the young, ambitious sur- Opie, in 1901. A recent graduate in the School of Medicine. geon acted upon his idea, marching into first class at the new Johns Hopkins Med- Each of these investigators was more the office of one of the most knowledge- ical School, Opie was riding the scientific or less successful at showing a hypoglyce- able carbohydrate physiologists of the flood tide, as we all try to do. He knew the mic effect of pancreas extract. But Zuelzer time, J.J.R. Macleod. Macleod was not so literature about diabetes and knew how to was never encouraged to pursue his work, immediately struck by the merits of duct make careful observations of pancreatic apparently because he was Jewish and ligation. He knew very well that the islets histology. And the tide of information had lacked social status. Scott gave aqueous contained the antidiabetic factor and risen to the point where Opie could make extracts of pancreas intravenously to pan- knew that its isolation could treat diabe- acrucialdiscovery.Writinginsmallspiral- createctomized dogs and reported “a tes; after all, that concept had been com- bound notebooks with a fine, precise slight diminution of glycosuria” accord- mon knowledge for almost 20 years. handwriting that I have been privileged to ing to Allen, but Allen dismissed his find- Perhaps Macleod did not take full account see, he defined the purpose of the islets of ings as “doubtless explained by renal or of the fact that the tide of science had risen Langerhans and the source of what was to other nonspecific changes” (15). Kleiner’s and advances in laboratory technique become known as insulin: work was interrupted by , might now allow the successful extraction and he never returned to it (14). The Ro- of the internal secretion. At any rate, he I have described two types of chronic pan- manians still feel strongly that Paulesco could hardly have missed the personal creatitis. . . . Where diabetes was absent, should receive credit for first discovering drive of , and he did ul- the islands of Langerhans persisted unal- insulin. timately support Banting’s work, even tered....Inthepresent case, however, di- Bliss also emphasizes that small, steering a bright young student, Charles abetes followed a lesion affecting only the islands of Langerhans....Diabetes melli- seemingly technical advances were cru- Best, in his direction for the summer. tus. . . is caused by destruction of the is- cial. For example, the ability to measure The rest, as they say, is history. Insu- lands of Langerhans and occurs only when glucose quickly, without waiting for days lin was “discovered,” Banting (and Ma- these bodies are in part or wholly destroyed. or weeks of analytic time, was credited to cleod) received their Nobel Prizes, and (11) Lewis and Benedict. As a technique, it was the story quickly reached mythical pro- just as important to the discovery of insu- portions (albeit while quickly turning ac- With this and subsequent publica- lin in 1921 as was PCR to the sequencing rimonious on a personal level, almost to tions by Opie (12,13), the process of dis- of the human genome in our own time. the point of within-lab fist fights). Look- covery had progressed from a simple Although frequently on the verge, ing back at this sequence, we see that description of these cells, without known none of these investigators in the first two Banting, whatever personal strengths and function, to the understanding that diabe- decades of the 20th century reached the persistence he had, was not a genius, and tes was caused by something in the pan- point of using pancreas extracts in hu- this triumph did not result from his Idea. creas, to the observation that the islets of mans, however. Until 1920, consumma- It resulted from the gradual accumulation Langerhans did in fact contain the antidi- tion was denied for one reason or another. of knowledge and technical progress, abetic factor missing in diabetes. Each sci- The glory was left for the Toronto group. from the rising tide (18) and the efforts of entist was building on what was already In October of 1920, Frederick many. Specifically, as it turns out, known, each aware of the relevant Banting jotted his famous note to himself, Banting’s triumph was probably not at all literature. what he later repeatedly referred to as related to his duct-ligation idea, but to the

DIABETES CARE, VOLUME 26, NUMBER 2, FEBRUARY 2003 521 Presidential Address fact that scientists in 1920 knew enough scientific life we now have through our 1961, a professor of sociology at Colum- to keep the tissue on ice (19) and that publications and major scientific bia University named Robert K. Merton their chemist, J.B. Collip, knew how to meetings. cited a compilation of 150 cases of scien- purify a crude alcohol extract. Not that these early sociologists of sci- tific discovery (26). He concluded that it I should also add that as honors were ence were perfect. In another passage is the rule, not the exception, for discov- showered on Banting—and to a lesser ex- from the 17th century, the first historian eries to occur in multiple places almost tent Best, Macleod, and Collip—industry of the Royal Society, “fat Tom Sprat,” rec- simultaneously: was the unsung hero of the time. Con- ommended, naught Laboratories, Eli Lilly and Com- . . . far from being odd or curious or re- pany, and Nordisk Insulin Laboratory . . . even joyning [sic] [scientists] into com- markable, the pattern of independent mul- each made enormous contributions by mittees, if we may use that word in a Philo- tiple discoveries in science is the dominant sophical sence [sic], and so in some measure pattern.... Itisthe singletons— ramping up production and making com- discoveries made only once in the history of mercial-grade insulin widely available purge it from the ill sound, which it for- merly had. (23) science—that require special explana- within a matter of months. tion.... Put even more sharply, the hy- But to summarize, when I see the And some of us may disagree when Bacon pothesis states that all scientific discoveries number of people about to successfully are in principle multiples. (27) characterized scientists as “men abound- extract insulin, as well as the sequence of ing in leisure time” (20). events that was ultimately successful, The best evidence for this may be our It is remarkable, however, how fully from Langerhans through Minkowski and everyday behavior as we practice science: we have realized Bacon’s prediction that Opie to the Toronto group, I have to con- Why do we rush to get our papers sub- we would be meeting to share the labors clude that the discovery of insulin was mitted and into print? Because if we don’t of many. This is exactly how I see the ADA inevitable. It was going to happen some- do it first, someone else will, and soon. Scientific Sessions. We share results, where, if not within months then cer- Why was sequencing the human genome ideas, and opinions. We share at the po- tainly within a few years. (And I know such a personal race between Craig Ven- diums and in the lobbies, the restaurants, that in drawing this revisionist historical ter and Francis Collins? Because two the bars, and the airports. And we have conclusion, I risk the ire of at least some of groups, two methods, were each capable certainly realized Sprat’s recommenda- my Canadian friends.) of doing it. The tools were there last year tion that we all form committees! Now, is this a new idea of mine, that for cloning the human genome, just as the But there is another part of Bacon’s progress in science is inevitable, depen- tools were there in 1921 for extracting theory that struck me: the notion that sci- dent less on individual genius than on insulin. ence “leaves little to the acuteness and time? Hardly. It turns out that the theory Why did Banting spend the rest of his strength of wits, but places all wits and of the inevitability of scientific discovery life, well documented in other works by understandings nearly on a level.” This dates back at least to the early 17th cen- Bliss (28,29), futilely trying to make an- concept suggests that various people tury, actually to a contemporary of Shake- other major discovery, trying to cure can- might have the same ideas and make the speare (assuming he was not actually cer or treat sepsis, when for most of us same advances simultaneously and inde- Shakespeare), Sir Francis Bacon: discovering insulin would have been pendently. plenty for one career? Because he too was The path of science is not. . . such that only I was fascinated to find this confirmed trying, in effect, to disprove Bacon, trying one man can tread it at a time. (20) in the Journal of the American Medical As- to show that he was better than, not just sociation’s theme edition on diabetes in . . . all innovations [social or scientific]... “nearly on a level” with, other scientists. May 2002, with the mention of a new He was trying to work well in advance of are the births of time....Time is the great- name and a story that was new to me at est innovator. (21) the rising tide of science (as he had done least. The name is Leonid V. Ssobolew, a also in the fall of 1920 in proposing to Bacon, who is acknowledged as one of the Russian scientist working at the turn of “graft,” or transplant, ). greatest geniuses of all time, even con- the century in St. Petersburg—as it turns The question then becomes: Are these ceded that “the course I propose for dis- out, in the laboratory of Professor Pavlov academic/scientific rivalries nothing more covery of sciences is such as leaves but (24). Ssobolew was reaching exactly the than minor ego trips, little ripples on the little to the acuteness and strength of wits, same conclusions, at the same time, as rising tide? Does it really matter who but places all wits and understandings was Eugene Opie: reaches a goal first, who publishes the first nearly on a level” (22). The promise of In fifteen cases of diabetes, Ssobolew found report and claims primacy? science, he suggests, is to be realized by more or less well-marked changes in the I would answer that yes, it matters. “[scientists] working in association with Langerhans islands in practically all the cas- Let the competition go on. I believe that one another, generation after generation” es....Unfortunately Ssobolew, in his re- competition does spur advances, whether (20). view of the literature, omits entirely it is capitalism or the World Cup. Com- Bacon, then, was emphasizing the references to the American literature. (25) petition speeds the process, catalyzes the central importance of social and profes- reaction. And it is important for scientific sional interaction among scientists, of This is a striking coincidence: the advances to move to the clinic just as communication, sharing knowledge and same discovery being made at the same quickly as possible. It makes a difference. discoveries. He seemed to anticipate, al- time, independently, in and in For one thing, there are individual most 400 years ago, exactly the sort of St. Petersburg. Or was it coincidence? In lives at stake, as people with diabetes

522 DIABETES CARE, VOLUME 26, NUMBER 2, FEBRUARY 2003 Presidential Address await a scientific, therapeutic, or clinical to help your patients, consulting with a Scientists learn to focus their research practice advance. Bliss dramatically de- colleague, sharing your own expertise, or questions by exposure to the clinical is- scribes the condition of children on the enhancing that expertise by reading or by sues facing practitioners and the clinical diabetes ward at Toronto General Hospi- listening to reports at a scientific meeting. problems facing people with diabetes. Re- tal in January of 1922 (30). They were on Each individual effort moves the science cently, I talked with a basic scientist on the verge of death from ketoacidosis, un- and the practice of diabetes to a new, his way to a diabetes congress specifically dergoing the torture of therapeutic starva- higher level, taking part in the rising tide in order to learn more about clinical dia- tion diets, and would never have survived of science and medicine, and the ADA betes. The ADA brings these worlds had not the so-called Banting Extract been brings together as fine a group of scien- together. injected. tists and clinicians as can be found any- We also bring people together, liter- As it turned out, the first child to re- where. ally, from all over the world. International ceive insulin, Leonard Thompson, lived It is worth asking, then, how did this attendees now make up close to half of the 13 years longer, thanks to insulin, before ADA Professional Section meeting begin? registrants at the ADA Scientific Sessions, dying of bronchopneumonia (31). The Bacon could hardly have anticipated the about 6,000 people. We are enormously first American to receive insulin, Jim Ha- present-day Scientific Sessions, with its happy and honored to have them come vens, lived 49 years thereafter, ultimately enormous aggregation of brains, commit- and share their research, their expertise, dying of cancer. And a third, Elizabeth ment, professional accomplishment, and and their perspective at what has become Hughes, lived a remarkably productive altruism. I doubt that even the founders of a truly international meeting. life on insulin therapy until 1981, 59 the ADA could have imagined it as they Another great and distinguishing fea- years after her first injection of the crude met over lunch at a Schraft’s Restaurant in ture of the ADA is the inclusion of all extract. (Elizabeth Hughes’ father, New York City in 1941 to formalize a new health care professionals. In the ADA Pro- , incidentally, was a professional association. fessional Section, we equally seek, re- U.S. Supreme Court justice memorialized When the ADA was founded, it all spect, promote, and value members of all in John F. Kennedy’s Profiles in Courage looked small and, to current sensibilities, the health care professions. We have ma- for a courageous stand taken in 1920, de- embarrassingly conventional. A group of jor representation of nurses, nutritionists, fending a group of Socialists.) I personally distinguished physicians, all white, all podiatrists, pharmacists, behaviorists, happen to have seen a patient recently male, most probably all with significant and health policy makers. Our top lead- whose father was saved by insulin in visceral adiposity, and all wearing bow ership posts reflect this emphasis in the Brooklyn, New York, in 1922. Those were ties for their inaugural photograph. But to position of President, Health Care and dramatic days in the treatment of diabe- their credit, they were actively, devotedly Education, held by my colleague, Anne tes. treating diabetes and asking the impor- Daly. So advances in clinical research do tant questions of their time: How do we One of the ADA’s very proudest save lives, and this can never be dis- use the new insulin formulations? What is achievements has been to promote diabe- counted. the proper role for these new diabetes tes education and to nurture a whole new Nor does this theory that science pills? How tightly should we control profession—the Certified Diabetes Edu- “places all wits and understandings nearly blood glucose? How can we preserve cator—as well as to recognize excellence on a level” minimize the importance of limbs and eyes and kidneys? Familiar in diabetes education programs. I have individual leaders. There are always sounding questions. said many times that diabetes education is standouts, people leading the way in A hallmark of the ADA has been its the single greatest advance in diabetes American science and around the world. embrace of growth and change, its accep- care—ever. They receive credit, and they deserve tance of cross-fertilization. It did not stay But surely we can improve. We have credit. But you will have noticed that vir- all middle-aged white men for long. To to learn to better meet the needs of each tually every time an honorary lectureship begin with, strong and accomplished professional group. We have to get to is delivered, the lecturer ends by thanking women excelled in the field of diabetes, know each other better and respect each a long list of collaborators. Surely, medi- women like Priscilla White at Joslin, No- other more. We need to learn the right cal science is in fact a “joint labor of bel Laureates Dorothy Hodgkin of Oxford balance between thoroughness and bu- many.” and Roslyn Yalow in the Bronx, Banting reaucracy, between high standards and Nor should crediting science as a Award winner Ora Rosen of Albert Ein- excessive burdens. whole be an abstract, impersonal concept. stein, and more recently, Kathleen Wish- In 1970, the ADA took yet another In fact, we are crediting individual accom- ner, our first female president, and radical next step. We expanded beyond plishment: the many, many individual Francine Kaufman, my successor. the notion of a professionals-only associ- scientists from around the world who Almost from the start, the ADA ation, welcoming as equal partners non– over the years have contributed to the ris- brought clinicians and scientists together, health care professionals. The so-called ing tide of medicine. In crediting the rejecting the restrictions imposed by be- lay section is now in full partnership with whole scientific community, we are in ef- ing either a clinical or a research society. the professional section and led by the fect paying homage to each of you, scien- We now have a membership and a bal- Chairman of the Board of Directors, my tists and clinicians, as you congregate at anced program of basic and clinical sci- colleague Stephen Smith, in our year. Un- this ADA meeting. Each of you plays a ence, research, education, and practice. der Steve, non–health care professionals part, when writing up a new contribution We believe that clinicians enjoy the intel- led many of the committees and task to the literature, figuring out a better way lectual “fix” of hearing the latest science. forces of the ADA.

DIABETES CARE, VOLUME 26, NUMBER 2, FEBRUARY 2003 523 Presidential Address

The lay section offers experience and alty, and that is fine. They are the institu- Acknowledgments— I acknowledge my spe- expertise outside of the health profes- tions or offices we work in, other specialty cial debt to, and dependence upon, the work sional world—in the worlds of finance, or professional societies that we belong of Professor Michael Bliss, whom I consider law, advocacy, marketing, fund raising, to, and of course the many, many national the leading authority on the history of the dis- and many others. And they add another diabetes associations and societies around covery of insulin. I also wish to thank my unique perspective: for most of the lay the world. Each of these groups plays a friends at the ADA, Richard Kahn, John Gra- section, diabetes is a very personal is- part in the rising tide of diabetes research ham, Caroline Stevens, and many others, for sue—to a parent, to a child, to a friend, or and care. their insights and support; Nancy McCall, Ar- to themselves. They support our research I hope that even with these other pro- chivist, William McChesney Martin Archives program and the broad array of ADA ac- fessional affiliations, however, you will al- of Medicine, ; Chris- tivities, not just intellectually or profes- ways consider the ADA to be your home tine A. Ruggere, Curator, Institute of the His- tory of Medicine Historical Collection, Johns sionally, but emotionally. As Alan Alda or your home-away-from-home. I hope Hopkins University; William Hughes, MD, once said in a medical school graduation that you will find our meetings stimulat- Washington, DC, for discussions of his grand- address, “The head bone’s connected to ing, our publications worthy, and our ad- father, Eugene Opie; Sharon Blackburn for the heart bone.” There is no question that vocacy valuable, and I hope that you will slide preparation; and of course my wife, Su- the lay section, embodying as it does the find the ADA welcoming to you as san, and my family, always. motto “Cure. Care. Commitment,” is the professionals. single most important reason that the There is still so much work to be done CHRISTOPHER D. SAUDEK, MD ADA has grown so remarkably. together, so much to be understood and Address correspondence to Christopher D. Saudek, The permanent staff of the ADA is also discovered. We have come a great dis- MD, Johns Hopkins University Medical School, Os- unique in its level of expertise and com- tance up the beach since 1902, but we are ler Building, Room 576, , mitment. Ably led by Chief Executive Of- still a long way from high tide. Do we Baltimore, MD 21287. E-mail: [email protected]. ficer John Graham, they see to it that the really understand something as funda- This address was delivered at the 62nd Annual scientific standards are set and main- mental as the immunology of type 1 dia- Meeting and Scientific Sessions of the American Di- abetes Association, San Francisco, California, tained, meetings are held, advocacy is ef- betes? Do we know the genes that 14–18 June 2002. fective, publications are published, predispose to type 2? We know what stem positions and policies are accurate, the cells are, but can we direct them to take ●●●●●●●●●●●●●●●●●●●●●●● camps are staffed, the grants are awarded, up a career as ␤-cells? Can we deliver in- References and the funds are raised to fuel this won- sulin physiologically with mechanical de- 1. von Engelhardt D: Diabetes: Its Medical derful organization. vices or transplant islets and maintain and Cultural History. Berlin, Springer-Ver- I mention the components of the ADA them without immunosuppression? Do lag, 1989, p. 3 not just for your interest. There’sno we even understand the educational keys 2. Adams F (Ed., translator): The Extant doubt that it is a big, complex, successful that result in good self-care or the eco- Works of Aretaeus, the Capadocian. Lon- organization—one of the very largest vol- nomic factors that will allow us to deliver don, The Sydenham Society, 1856, p. untary health organizations in the world, the most cost-effective care? 38–40. Quoted in Sanders LJ: The Phila- telic : In Search of a Cure. and in my biased opinion, the best. But There is no doubt in my mind that the Alexandria, VA, American Diabetes Asso- my point is that the ADA’s very size and most dramatic, definitive discoveries are ciation, 2001 diversity distinguish it among profes- yet to be made. That is what makes re- 3. Diabetes as a manifold disease. JAMA 38: sional and voluntary health associations. search and care in diabetes such an excit- 402, 1902. Reprinted in JAMA 287:692, Very few other organizations have this ing, rewarding field. 2002 scope; very few have even sought to inte- It will take time—years, maybe de- 4. Allen FM: Glycosuria and Diabetes. Boston, grate different health professionals, much cades—to answer these questions. It will W.M. Leonard, 1913, p. 790 less join hands with a powerful lay mem- take an ongoing commitment, not only 5. Bliss M: William Osler: A Life in Medicine. bership. from scientists and not only from the New York, , 1999 A certain basketball coach of a certain ADA, but from society as a whole. Because 6. Osler W: The Principles and Practice of Medicine. New York, D. Appleton and Co., national championship team uses a quote without question the gravitational force 1892 said to have been cribbed from Kipling: that pulls the rising tide of science is mon- 7. Harvey AM, McKusick VA (Eds.): Osler’s “The strength of the wolf is in the pack, ey: funding for the broad-based, modern Textbook Revisited. New York, Appleton- and the strength of the pack is in the scientific research enterprise; funding for Century-Croft, 1967 wolf.” In the ADA as in so much else, it all modern, team-oriented diabetes care. 8. Bliss M: The Discovery of Insulin. Reprint comes down to individuals acting in con- So I want, in closing, to offer each of ed. Chicago, Univ. of Chicago, 1984 cert with one another. It comes down to you a challenge, whether you are a visitor 9. Personal notes of Eugene Opie, courtesy those of you who attend our meetings, to our association or a long-time member. of Alan Mason Chesney Medical Archives, read our publications, submit your manu- I challenge you to take hold of the best in Johns Hopkins University, and of Dr. Wil- scripts, win our research grants, and sup- ADA. Take it back to wherever you work liam Hughes, Washington, DC 10. Houssay BA: The discovery of pancreatic port our cause. and use it, improve on it, do it better, and diabetes: the role of Oscar Minkowski. In Of course the ADA cannot possibly come back for more. Because in this way, Diabetes: Its Medical and Cultural History. fill all the professional needs of such a each of you, each of us, will contribute to von Engelhardt D, Ed. Berlin, Springer- diverse membership. We all belong to the rising tide of diabetes research and Verlag, 1989, p. 350–358 other organizations that deserve our loy- care, until we have, in fact, found a cure. 11. 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