of Medical Sciences, University of Turin, Turin, Italy
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Abstract
The onset of disproportionate urination has been known since the mists of time, as was the notion that urine emitted in large quantity was often sweet and had the property of attracting bees, flies and other arthropods, or even vertebrates. Mention of diabetes is made in ancient medical textbooks from China, India, and Egypt. In Roman times, Aulus Cornelius Celsus and Rufus of Ephesus commented on polyuria, polydipsia, and weight loss, while Aretaeus of Cappadocia gave the first full clinical and empathic account of the signs, symptoms, and deep discomfort experienced by patients. Islamic medicine brought few contributions to diabetology, as did the Schola Medica Salernitana in the Middle Ages. In 1676, Thomas Willis was the first to establish a distinction between diabetes “mellitus,” where the urine is as sweet as honey, and the other forms of polyuria, and Matthew Dobson demonstrated in 1776 that the sweet taste was due to the presence of sugars capable of fermentation. This led John Rollo, Surgeon-General of the Royal Artillery, to strictly limit carbohydrates in his “rancid” diet. Finally, in 1815, the French chemist Michel-Eugène Chevreul identified the sugar as glucose, opening the way to its quantitation for diagnostic and therapeutic purposes. In 1806, the Englishman Willian Hyde Wollaston showed the presence of sugar in the blood, and in 1855 Claude Bernard theorized that diabetes was the result of overproduction of glucose by the liver. Also in France, Apollinaire Bouchardat suggested the suppression of bread and almost all other carbohydrates from the diet but conceded their partial reintroduction after the disappearance of glycosuria, which the patients could detect by tasting their own urine, a first in self-management! Finally, in 1889, von Mering and Minkowski published their paper on pancreatic diabetes, opening the way to 30 years of search for a pancreatic extract that could have therapeutic value.
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The onset of disproportionate urination has been known since the mists of time, as was the notion that urines emitted in large quantity were often sweet and had the property of attracting bees, flies and other arthropods, or even vertebrates.
Ancient Oriental Medicine
A classic description of diabetes is contained in the Nei Ching Su Wen, a famous book of internal medicine attributed to Huang Ti, the Yellow Emperor (ca. 2696 BC), although historians now believe the book is more recent, going back to circa 1000 BC. In later years, on the basis of the Yin-Yang paradigm, Chinese medicine still recommended that a physician should concern himself with urine, an expression of spilling of the Yin. Since about 200 AD, mention is made of “sweet urine that attracts dogs” among the symptoms of “Xiao-Ke,” or “thirst effusing into urine” [1, 2]. Indeed, the Chinese name for diabetes, táng niăo bìng (糖尿病), means “sugar urine disease.” In the 7th century AD, Li Hsuan noted that patients with diabetes were prone to boils and lung infections and prescribed avoidance of sex and wine as treatment.
Sanskrit medical tradition, extending from 2500 to 600 BC, with the Charaka Sahmita and Susruta Sahmita (Charaka’s and Susruta’s textbooks of Hindu medicine) [3, 4] included “sweet urines” among the twenty disorders of urination, collectively described as “prameha” (literally, “to micturate abnormally” or simply “polyuria”). Of the 20 varieties of “prameha,” 10 derived from phlegma and were curable, 6 from the bile and could be eliminated, whereas 4 derived from the air and were incurable. The latter affected “individuals with flaccidity of the flesh, sweet taste in the mouth, dryness of the throat, burning of the palms in the hands and feet and flux of urine as sweet as cane sugar [iksumeha] or honey [madhumeha].” Urine tasting was recommended practice, with the annotation that the urines, and sometimes the patient’s body itself, had the property of attracting large black ants and flies, insects that another medical text – the Canidana – confirmed as being extraordinarily inclined towards sweetness. Such variety of “prameha” was associated with “astimeha,” or excess of clear urine (as seen in elephants in heat) and thirst. The presence of major drowsiness and breath scenting of rotten fruit or fermented fluid (“surameha”) was also mentioned in association, suggesting that the syndrome we know today as diabetes mellitus had been identified. If these symptoms appeared in an overweight individual, fasting was recommended.
Such reports from oriental medicine do not appear to have spilled over westwards. There is no mention of them in Sumerian or Babylonian sources, such as Hammurabi’s code or what remains of the Treatise on Diagnosis and Prognosis from the 18th century BC.
Egypt
The idea that the Egyptians had identified diabetes as a specific disease is incorrect. The only known source of information is the Ebers Papyrus (ca. 1500 BC), the most extensive and best-preserved medical papyrus to have survived, collecting notions on health matters going back perhaps to 3000 BC. Found between the legs of a mummy in Luxor, it was bought in Thebes in 1862 by the American Egyptologist Edwin Smith, who sold it in 1872 to Georg Moritz Ebers (1837–1898), professor of archaeology in Berlin and Leipzig and a good writer of popular, not only scientific, literature (Fig. 1). It is currently housed in the university library at Leipzig. The papyrus, a 20-m long, 30-cm wide roll, contains information on more than 700 recipes and 400 medicinal preparations for the treatment of stomach, heart, eye, skin, tooth diseases and numerous other conditions, including some mental disorders such as dementia and depression. Prescriptions include all possible resources from the mineral, vegetable and animal kingdoms, together with the ancillary mystical-magical-religious rituals. No specific mention is made of diabetes as such, except for a group of 15 prescriptions for excessive urination: infusions, pills, enemas, and the like. Ingredients include gum, resins, minced wheat, sundry fruits and roots, coloquintida, honey, juniper berries, grapes, terebinth, ochre, barley, linen seeds, hematite, verdigris, sweet beer, oil, animal fat, urine itself, and salt from low Egypt. Mention is made of a potion consisting of pond water, elderberry, asit fibers, fresh milk, beer foam, cucumber flower, and green dates. Except for occasional remarks (“excellent”), we have no reports on the effectiveness of such remedies [1, 5].
Fig. 1. George Moritz Ebers (1837–1898). Portrait, ca. 1890. Reproduced with permission of Griffith Institute, University of Oxford, UK.
Diabetes in Old Western Medicine
The Greeks had some knowledge of sugar, which they called “Indian salt,” suggesting some influence from the Far East in the times of Hippocrates (ca. 460–370 BC), who made reference to “watery urines” as a bad sign when passed too soon after drinking. Apollonius of Memphis and Demetrius of Apamea first used the term “diabetes” in the 3rd century BC, meaning the passing of large amounts of water through the body [1, 5].
Aulus Cornelius Celsus (25 BC to 50 AD), in his De Medicina Libri Octo, commented on polyuria, polydipsia, and weight loss and, interestingly, recommended physical exercise [6] (Fig.
