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A Look Back: Diabetes Then and Now

Editor's Note: The following article first appeared in the Spring 1996 Edition of the Voice of the Diabetic, the official publication of the Diabetics' Division of the National Federation of the Blind in the United States.

Although the Bible states that the years of a man shall be threescore and ten (70), average life expectancy in the ancient world was less than 40. Many died in infancy, or fell in battle. Diseases arising from poor sanitation, especially in the cities, took others. And then there was diabetes.

In the superstitious tribal world where disease process was not understood, and was frequently blamed on hostile magic, a man who sickened and died without immediately obvious cause was considered a spiritual battle casualty-victim of the nearest hostile witch doctor. Retaliation, not further study, was the order of the day.

In most of the ancient world, the presence of debilitating disease was considered evidence of spiritual pollution. Disease came from sin, and diseased persons were to be shunned. The Biblical treatment of leprosy is one such example. It is interesting to note that modern Hansen's Disease (leprosy) is quite different from the ancient scourge. One wonders just what disease process the ancients were observing.

Individual physicians recorded their observations. We have Egyptian documents (c 1500 BC) and Indian records (c 1000 BC). Hindu physicians Susruta and Charaka even described type I and type II diabetes, almost 3000 years ago! But these visionaries were battling the ethos of their time.

For all of the Egyptian physicians' skill with wound care and surgery, it was not until Classical Greece (550-300 BC) that the study of disease broke free of the constraints of religion. Greek physicians interpreted disease as imbalance rather than evidence of moral degeneracy. Freed from value judgment, they could study specific afflictions with clear eyes.

The great physicians' school at Kos, home of Hippocrates, taught that a healthy lifestyle, consisting of proper diet and plenty of exercise, was good therapy. It still is! Those diabetics who consulted Hippocrates and his fellows undoubtably received some benefit.

In 100 BC, Greek physician Aretaeus described the symptoms of diabetes in detail, and named the condition, from the word "dia-bainein"to pass out or pass through.

Hellenistic and Roman physicians drew on the work of Greek masters, but, over time, the process of inquiry dwindled. Knowledge repeated too long without question becomes dogma, not science but an article of faith. The dark ages of medicine arrived even before the fall of Rome.

In Medieval times, as in so much of the ancient world, the person with a disease was seen as a moral degenerate-someone needing expiation, remission, absolution, forgiveness and not someone whose body was simply malfunctioning. Since ill health was evidence of moral imperfection, families took pains to conceal their chronically ill or disabled members from public view. The word idiot comes from Greek idiotike, meaning something private. When the morality of the sufferer was automatically in question, rational inquiry was not likely. Not until the Renaissance would the lot of the diabetic improve.

Tracking diabetes in the Middle Ages is like navigating in a fog. There are tantalizing hints that the Anglo-Saxon Royal House of Wessex, the family of Alfred the Great, Athelstan, Edgar, and Edmund Ironside, was diabetic. All these great leaders sickened in their early thirties, dying shortly after. Chroniclers, who didn't recognize the cause, made it clear the condition was inherited; and that each scion of the Royal family was watched closely as he approached the vulnerable age.

The Renaissance brought renewed interest in medicine, and a return to the search for rational explanation of disease process. Although early studies focused on pestilence (plague, malaria, smallpox), understanding of diabetes improved as well.

In 1650, researcher Thomas Willis described the sweet taste of urine in people with diabetes. In 1750, a scientist named Cullen added mellitus, Greek for honey-sweet to the name of the condition, which now aptly described the urine-passes through honey-sweet.

Not until the late 19th century was the source of diabetes identified. Paul Langerhans, who described the islet cells of the pancreas in 1869, misidentified them as lymph glands. But in 1889 Von Mering and Minkowski proved that removal of the pancreas in dogs caused diabetes, and in 1901 Eugene Opie clearly linked diabetes to the islet cells.

In 1910, urinalysis for the measurement of blood glucose was developed. Diabetes could now be easily and reliably diagnosed but nothing could be done for it. The loss of insulin action meant the same thing in 1915 as in 1015, an early death.

Real progress came with the identification of insulin action. In 1921 Banting and Best extracted insulin from the pancreases of dogs, and almost immediately animal source insulin, what we now call regular or short-acting, was made available for the treatment of diabetes.

Early advertisements make it clear that the nature of insulin was not widely understood. In 1926, Metropolitan Life reminded readers of the National Geographic: Occasionally a patient, under insulin treatment, feels so much better that he is tempted to abandon his diet and eat everything he wants. But when he does, he is likely to suffer a relapse and die. Then insulin is blamed.

For years insulin-dependent diabetics tested their urine (not blood), and used big, dull, reusable syringes to administer their insulin. Urinalysis was not the still-familiar visual test strip, but a matter of putting urine in a test tube, applying a chemical reagent, watching fizzing reaction, and making calculations based on both test results and food intake, to come up with the insulin dosage required for the next day. The calculations: Read test percentage, multiply by volume to get grams, calculate food intake (grams of carbohydrate x1, of protein x4, of fat x9), subtract that from total, divide by insulin units taken = next day's dose, are probably beyond today's math competence without a computer. However difficult, life with diabetes in the early days of insulin was vastly better than the alternative! In 1936, PZT insulin, a long-acting type, was developed, and in 1938, the familiar NPH. Now insulins could be mixed. The outlook for diabetics had improved so much that a Metropolitan Life advertisement, dated May 1941, could state, "The diabetic whose disease is discovered early; who promptly puts himself under and stays under his physician's guidance; and who masters the details of his treatment, stands a good chance of living as long as he could reasonably expect to live without diabetes." What a long way we had come.

1952 saw the introduction of intermediate-duration Lente insulin, and 1956 saw the first of the sulfonylureas, oral medications to lower glucose in type II diabetics. Up through the 1960s, however, urinalysis and reusable syringes were still the rule. When it took a week just to get the result of a blood test back from the hospital pathology lab, tight control was hardly possible.

In 1961 Becton Dickinson introduced the single-use syringe, and in 1969 Ames Diagnostics introduced the first portable, fairly instantaneous, blood glucose meter. Ten years later, glucometers for home use became standard.

Innovations have come rapidly. Glucometers with voice synthesis for the blind and visually impaired, recombinant-DNA insulin, easier testing procedures, new oral medications for better control of type II diabetes and and in 1993 the results of the Diabetes Control and Complications Trial, the huge, federally-funded study that proved the best approach to diabetes management was to keep closely to the blood sugar levels of the non-diabetic.

We look back, and the past looks quaint and barbaric. Non-invasive, blood glucose testing is on the horizon. Our children will look at our ridiculous glucometers and horrid little lancets, and laugh, glad that they live in a better day. As we in our dotage tour the museum, of medical curiosities, gazing again on lancets and test strips, let us remind our descendants that though the tools change, each generation must do the best it can with the tools it has on hand.

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