Bittersweet: Diabetes, Insulin and the Transformation of Illness

Bittersweet: Diabetes, Insulin and the Transformation of Illness A new book examines the patients treated by diabetologist Elliot Joslin before, during, and after the discovery of insulin. journalArticle dibetes,control,syndrme,insulin,mellitis,controle,latent, diabetes/endocrinology,adults,fh,mellutis,mellitus,DM,syndrum,controlle,histroy,fm, diabetes mellitus type I uncontrolled, diabetes mellitus type II with complications,syndrdome,diavbetes,daabetes, diabetes mellitus type I,sindrome,daibetes,diabetes,autoimmune, insulin resistance syndrome,unconrolled,hisstory,diabetis,nidm,insulin dependent diabetes mellitus,juvenile onset diabetes,mature,worse,diabetus,history,family history,controlled,uncoltrolled,dependent,melllitus,syndroms,familial,dibaetes,syndromes,melliutus, continuous subcutaneous insulin infusion,poorly,fhx, CSII,syndrom,dm,syndorme,lada,young, diabetes mellitus family hx,cntrol,type 1,fam,type 2,requiring,ho,mody,dep,fmh,diabtes, diabetes mellitus type II uncontrolled,poor,sugar,diaabetes,mellittus,melitus,histrory,syundrome,h,uncomplicated,diabeties,niddm, diabetes mellitus type II juvenile onset,medical,o,melltius,diabetes mellitus,sindrme,non insulin dependent diabetes mellitus,type2,typeii,dabetes,syndriome,compl,diabets, diabetes mellitus type I adult onset,iddm,melletis Reviewer: Alan L. Rubin, MD Alan L. Rubin, MD, author of Diabetes for Dummies and Diabetes Cookbook for Dummies. He is in practice in San Francisco, California. Medscape Medscape General Medicine 10/14/2003 5 4 By Chris Feudtner The University of North Carolina Press Copyright 2003 312 Pages ISBN: 0-8078-2791-6 $29.95 hardcover When it was first purified in 1921, insulin was hailed as the cure for diabetes. Children who might live a maximum of 3 years after the diagnosis were living decades longer. The great diabetologist Elliot Joslin, reviewing the first year of insulin use, said of his medical practice, "this past year has been among the erstwhile dead."[1] Joslin and the rest of the people treating diabetes were soon to realize that the discovery of insulin was really a tradeoff. In place of a few years of life after the diagnosis, people with insulin-dependent diabetes would live to suffer the complications of diabetes in later years: eye disease, kidney disease, nerve disease, and heart disease. In Bittersweet: Diabetes, Insulin and the Transformation of Illness, author Chris Feudtner, MD, PhD, MPH, a pediatrician at the Children's Hospital of Philadelphia, focuses on this story. He uses diabetes as an example of how a treatment can transform an illness into something different, unexpected, and sometimes lethal. Dr. Feudtner writes: "I want to assist those who deal with diabetes and other chronic illnesses to understand how medicine transforms disease and how patients and the health care system interact and adapt." He adds, "I hope that this work underscores modern medical practice's recurrent irony of solving one problem but creating new ones...But most important, I hope that by restoring the experience of patients, we might remember the past more clearly, helping current patients and those who care for them to make better sense of the lives they live" (xvii). Feudtner uses case histories drawn from the voluminous medical records of Elliot Joslin and his clinic to tell the stories of various patients treated by Joslin before, during, and after the discovery of insulin. Joslin was a meticulous record keeper, and the files contain all of his thoughts about the patients as well as letters written by the patients and their private doctors and loved ones, especially mothers and wives. Dr. Feudtner reviewed more than a hundred of these cases and stopped when new cases added nothing more to his understanding of the illness and its treatment. For the most part, the author succeeds in his objectives. He shows that insulin was not the panacea it was thought to be at first. Some of the lives drawn from Joslin's records are not happy ones, and some are downright tragic. However, it is important to keep in mind that Elliot Joslin died in 1962. This was before the use of the most important advance in diabetes treatment since insulin, patient self-testing of blood glucose. This was before the invention of the insulin pump and the discovery of the use of the hemoglobin A1c test to guide treatment. Joslin never had the benefit of insulin glargine or lispro insulin, two major contributors to intensive diabetic treatment. Treatment today is light years ahead of what Joslin was able to do. The vast majority of pregnant type 1 diabetics have a benign pregnancy and deliver a healthy baby. If it can be done for the pregnant diabetic, it can be done for any type 1 diabetic who is willing to invest the time, energy and, yes, monetary resources to accomplish the task. The tone of Bittersweet is pessimistic. Although Dr. Feudtner mentions the advances of the present, he does not feel that they make much of a difference. Moreover, there was little lightness in the book. Surely some of the patients had experiences that caused them to find a little humor in their condition. The exception was the series of cartoons in Chapter 4 drawn by one of Joslin's patients who was able to find some reason to laugh. The fact that Joslin kept them suggests he too appreciated the ironies of diabetes. It is a fact that treatment is a trade-off. However, the advance of science means that treatment will get closer and closer to curing disease without adding new disease. In the case of type 1 diabetes, it may mean eliminating the genetic predisposition that permits an attack on the pancreas to wipe out the production of insulin. It is only a matter of time. Meanwhile, for an understanding of type 1 diabetes before insulin and for the first 4 decades after insulin, Bittersweet will provide many useful insights and should be read by anyone who wants to understand how far we have come and how far we have to go. <ol> <li>Joslin E. Changing diabetic clientele. Transact Assoc Am Physicians. 1924;39:304-307.</li> </ol>