A Disease in Motion: Diabetes History and the New Paradigm of Transmuted Disease

PERSPECTIVES IN BIOLOGY AND MEDICINE Volume 39 ¦ Number 2 ¦ Winter 1996 A DISEASE IN MOTION: DIABETES HISTORY AND THE NEW PARADIGM OF TRANSMUTED DISEASE CHRIS FEUDTNER* All changed, changed utterly: A terrible beauty is born.—W. B. Yeats, 1921 [1] Diseases are not what they used to be [2]. Thumb through William Osier's 1892 textbook, The Principles and Practice of Medicine, and the pages testify that diseases in developed countries have changed dramatically during the intervening 100 years [3]. This remarkable sweep of change, on closer inspection, resolves into several patterns of disease alteration (see table 1). The two most prominent patterns reflect the decline of infectious illnesses and the concomitant rise of degenerative chronic ailments; many scholars have targeted these patterns of reciprocal diminishment and substitution as the most important processes of disSupported in part by a Dissertation Fellowship from the Agency for Health Care Policy Research, Grant No. HS07476-01; an NRSA Fellowship from the Agency for Health Care Policy Research administered by the Leonard Davis Institute, University of Pennsylvania; an ACOG-Ortho Fellowship in the History of American Obstetrics and Gynecology; and the Measey Foundation. The historical materials on which this article is based were drawn in part from an archive of letters exchanged between patients and doctors from the 1890s to the 1960s maintained in the medical records of the Joslin Diabetes Center, Boston, Massachusetts; their use accords with published guidelines [48]. I am grateful to the Center's Committee on Human Studies for permission to use their records. The comments and support of Lester Baker, Dimitri A. Christakis, Nicholas A. Christakis, Charles T. Feudtner, Renee C. Fox, Stephen B. Gruber, Charles E. Rosenberg, Brian L. Strom and James H. Warram are acknowledged. * Dept. of Pediatrics, Children's Hospital and Medical Center, University of Washington , Seattle, WA 98105.© 1996 by the University of Chicago. All rights reserved. 0031-5982/96/3802-0938$01.00 158 Chris Feudtner ¦ Diabetes: A Transmuted Disease TABLE 1 Patterns of Disease Change Eradicated or Diminished • Smallpox • Typhoid, diphtheria, measles Substituted • Atherosclerotic vascular disease • Cancers Relocated • Smallpox, cholera, and other epidemic diseases • Influenza • Diet-induced atherosclerotic vascular disease Emerged De Novo ' Lung Cancer • AIDS • Hantavirus, E. coli 0157:H7, Ebola virus, and other microbial pathogens Re-emerged • Tuberculosis and measles • Syphilis and gonorrhea • Drug-resistant bacterial infections Transmuted Patients Dependent Upon Medicines or Machines • Asthma, hemophilia, cardiac arrhythmias • Chronic renal dialysis or ventilator support Patients Treatedfor Cancer • Childhood leukemias with secondary tumors • Adults with breast, colon, or prostatic cancer Patients Who Survived ' Cardiac arrest with stroke • Premature birth with complications • Major trauma with brain or spinal cord injuries Patients Aided by Surgical Intervention • Coronary artery bypass graft • Transplant patients Patients Aided by Psychiatric Intervention • Schizophrenia • War-related mental illness Patients Aided by Medical Intervention • Cystic fibrosis • AIDS ease change [4-8]. Diseases have also relocated from one part of the globe to another, occasionally altering world history in their wake, as cholera and influenza have done [9, 10]. A fourth pattern occurs when diseases emerge de novo. Lung cancer, for instance, essentially did not exist until after the first World War, when many former soldiers had begun their habit of smoking tobacco while serving overseas [11, 12]; similarly, the epidemic of AIDS, as well as outbreaks of other new infectious ailments, represent disease emergence [13, 14]. A fifth pattern reflects the reemergence of diseases, such as tuberculosis, gonorrhea, Perspectives in Biology and Medicine, 39, 2 ¦ Winter 1996 | 159 Syphilis, or measles through drug resistance and lapses of social policy [15-18]. In the background, another process of disease change has gradually reshaped many of the illnesses that Americans encounter. From premature infants cared for in neonatal intensive care nurseries to children who have been cured of cancer, from adults on dialysis for end-stage renal failure to former soldiers who suffer the lingering effects of warrelated mental illness, many patients now live with the ironic consequences of "successful" therapeutic interventions that have transmuted their underlying disease from an acute to a chronic ailment [19—24]. Perhaps no other disease provides as illuminating an example of the transmutation of disease than type I (insulin-dependent) diabetes mellitus —and no practitioner was more...