In lieu of an abstract, here is a brief excerpt of the content:

Bulletin of the History of Medicine 78.2 (2004) 504-505



[Access article in PDF]
Chris Feudtner. Bittersweet: Diabetes, Insulin, and the Transformation of Illness. Studies in Social Medicine. Chapel Hill: University of North Carolina Press. 2003. xxiv + 290 pp. $29.95 (cloth, 0-8078-2791-6).

One of my most vivid memories of the first year of medical school was a lecture by a diabetic woman who had recently given birth. She had avoided numerous potential complications by a system of "tight control" that involved frequent checking of her blood sugar followed by administration of insulin. This talk was inspiring stuff for the first-year students, who surely left the class with a "can-do" attitude toward the control of diabetes mellitus. In Bittersweet, an excellent social and cultural history of the disease in the pre- and post-insulin eras, Chris Feudtner well recognizes this type of success story. He dramatically describes the introduction of insulin in 1922 and how this created a population of "erstwhile dead" (p. 132) snatched from the jaws of death.

But Feudtner also emphasizes the price paid by diabetic patients fortunate enough to have become ill when insulin or other treatments were available. Such individuals, he writes, have lived with "duties and chores that burden the present and difficulties and uncertainty that loom in the future" (p. 169). In the case of the lecturer above, her successful outcome depended on the constant surveillance of her blood sugar, strict limitations of her diet, and the avoidance of low blood sugar caused by too much insulin. In the case of diabetics in general, living with the disease portended future disease of the eyes, kidneys, nerves, and circulatory system.

Feudtner terms this bittersweet tradeoff between longevity and morbidity the "paradigm of disease transmutation" (p. 17). He convincingly argues that physicians and patients no longer experience the natural history of diabetes; rather, they deal with a new form of the disease, modified by a series of medical interventions. Accompanying the transmuted disease is a transformation of the illness experience: diabetics no longer need to undergo starvation diets in order [End Page 504] to survive, as was the case before insulin, nor do they often die acute deaths from the disease. But they now must address diabetes as a chronic disease, an "iatrogenic irony" in which complete success has proven "complex and elusive" (p. 43). What his study of transmuted disease and transformed illness has underscored for Feudtner are the remarkably divergent approaches that exist—among both patients and health-care providers—for addressing the conundrum of diabetes. He urges both physicians and historians to take note of these variable "illness perspectives" (p. 88) when trying to understand patients' experiences.

The author is able to make these conclusions based on a remarkable collection of patient records from Boston's Joslin Clinic (later the Joslin Diabetes Center). Elliott P. Joslin served as one of America's premier diabetologists from 1898 to 1961, thus encompassing the years before and after the introduction of insulin. He also kept meticulous records, which included detailed and often moving correspondence between himself, his colleagues, and their patients. As Feudtner explains, Joslin's brand of diabetes control was distinctive, a moralistic approach that entreated patients to adhere to a strict diet-and-insulin regimen. Many patients accepted his word as gospel, but some challenged him, such as a man who charged him with minimizing the likely side effects of his diabetes: "I do not fear the truth," he stated, "but I do fear ignorance, and therefore I resent very deeply not being informed truthfully" (p. 191). One of the most interesting challenges to Joslin appeared as a series of amusing cartoons sent to him by a devoted, but frustrated, patient. Feudtner reproduces these drawings to great effect.

In addition to its other attributes, Bittersweet is a very well written and well referenced book. Feudtner convincingly argues that scrutiny of individual patient experiences can truly illuminate the history of all diseases, not just diabetes. His final chapter proposes a framework that can match the true goals of...

pdf

Share