Bittersweet: Diabetes, Insulin, And The Transformation Of Illness

Bittersweet: Diabetes, Insulin, and the Transformation of Illness

From The New England Journal of MedicineWhat has been the impact of medical care on health over time? To answer that long-standing and still troubling question, Chris Feudtner has given us a term to use: bittersweet. Examining the history of insulin therapy, Feudtner describes what he calls the transformation of illness. The idea is simple enough, though it has not been stated so clearly and compellingly before now. Marvelous new therapeutic techniques often do not conquer or eradicate diseases but, instead, transform them. The introduction of insulin in 1922 transformed the acute, rapidly fatal course of a diabetic coma into a chronic illness that could be monitored and managed over the years. As a historian and a pediatrician, Feudtner is sensitive to the ironies implicit in insulin therapy. This treatment often stopped cold the ravages of ketoacidosis yet created in its wake a host of late complications in the vessels of the retina, brain, heart, and kidneys of patients with diabetes. The transformation of disease, as exemplified by the case of diabetes, is a valuable and elegant concept that serves to remind us that the tally sheet for medical science must carry a column for debit as well as credit. Feudtner builds on a meticulous examination of the clinical records and correspondence from the clinic of the famous Boston physician Elliott Joslin to chart the effects of insulin therapy on the physicians and patients who pioneered it. The sections about the patients who first encountered insulin are fascinating. What did this miracle drug mean for medical care? The records that Feudtner studied contain the lengthy correspondence of Joslin's original patients, who reported their successes and tribulations in using insulin. The treatment of diabetes allowed patients to be involved in the day-to-day technical control of a disease in a way that was unprecedented. Feudtner has carefully sorted through the documents of a first generation of patients who entered this regimen of regular injections, sugar monitoring, and dose adjustments. He notes that we find in these letters not private reflections on illness by its sufferers but something more selective. These people were writing to their doctor. They tailored their observations and reports carefully, needful in turn of the advice, attentiveness, skill, or sympathies of a physician. One especially poignant example is Guy Rainsford, who kept up a decades-long correspondence with Joslin and illustrated his medical concerns in part through a series of penciled cartoons. Rainsford's sketches featured himself as the quirky and irascible protagonist of an ongoing struggle against his ailing body, armed with, or beset by, a sometimes bewildering array of syringes, retorts, chemicals, and charts with which to manage his sugars. Insulin transformed the illnesses and the lives of the patients who came under its influence. The new drug equally transformed the outlook of the physicians who first prescribed it, as Feudtner compellingly shows. Insulin seemed surprisingly to make the smallest difference in the basic goals and constraints of daily medical practice. Early proponents of insulin treatment, like Joslin, recognized that they were at the cusp of a new era. Yet physicians carried over into this era many characteristics of their earlier regimens of treatment. The sections of the book about the treatment of childhood diabetes before 1922 are wonderfully informative. Treatment through aggressive dietary restrictions before the introduction of insulin manifested strikingly similar patterns of management. Frequent assays of urinary sugars guided vigilant attention to sugars and fats in the diet. Similar issues about the ability to comply with the rigors of medical advice arose in dietary treatments, so that similar themes emerged in the relationships between physicians and patients before and after insulin. What changed most were the expectations of success. The limitations of insulin trea