Medical History, 10 Minute Talks, History

10 Minute Talk & Tea: A Short History of Diabetic Healthcare

Museum of the Order of St John Mel Nightingale, Visitor Welcome Assistant

(Press play to listen to the talk!)


 

Diabetes is a lifelong condition in which the body’s ability to produce or respond to the hormone insulin is impaired, resulting in the abnormal metabolism of carbohydrates and elevated glucose levels. In recent history we have discovered many different types of diabetes. The two most recognisable types are Type 1, a chronic condition which the pancreas produces little or no insulin, and Type 2, which results from high blood sugar caused by insufficient insulin production and insulin resistance. These two types are typically treated differently, with the Type 1 focus being supplementing the body with the insulin it’s missing, and Type 2 partaking in measures to encourage the body’s insulin production and quality. There are other forms of diabetes, that aren’t usually acknowledged, like Gestational Diabetes, Type 3C, Mature Onset Diabetes of the Young, and Latent Autoimmune Diabetes in Adults. It is important for us to be aware of all these different types when looking back at the past as all these types existed long before they were ever officially discovered. The further back you go, the less understanding there was about the condition and its different forms and nuances.

Blue poster with the four main signs of diabetes listed in bold white (with the first letter in an orange box) as Toilet, Thirsty, Tired, Thinner
(The four main symptoms of diabetes as part of the 4Ts campaign, © Diabetes UK)

Some of the first mentions of diabetes come from two of the oldest known medical texts, the Sushruta and the Charaka Samhita. These were ancient Sanskrit texts written by Hindu physicians in India, in the first millennium BCE, and they called the condition “madhumeha” meaning honey wine. The descriptions and symptoms are very recognisable with unexplained fatigue and weight loss, dryness in the mouth, extreme thirst, and an increased frequency of urination with a pale and sweet urine. These symptoms have been used to identify the condition throughout history and continue to do so today, as can be seen with the 4T’s (Thirst, Tired, Toilet, Thinner) campaign launched by Diabetes UK in 2012.

In ancient India, the diagnosis was made by tasting a patient’s urine, or noting whether ants congregated around it. The sweetness of diabetic urine was later emphasised by the Chinese Physician Zhang Zhongjing in the 2nd and 3rd centuries. The disease was said to be the most common in people who were gluttonous and indulged in sweet and fatty foods. Physical exercise and liberal quantities of vegetables were prescribed to treat the condition.

The word diabetes was first used by Aretaeus of Cappadokia in the 2nd century. The term meant “to run through a siphon” in Ancient Greek and referred to the large increase in urine production. Aretaus said that the condition was fortunately a rare disease, but still wrote extensively on it where he called diabetes a “wonderful affection” involving the “melting down of flesh and limbs into urine”. He emphasised in his text the excessive drinking and urination of his patients but also the nausea, restlessness, and quickness of death in some cases. He prescribed milk, cereals, starch, autumn fruits and sweet wines as well as bloodletting, cupping, and purgation.

Watercolour painting of a lightly tanned older man with a well shaped dark beard and a white turban.
(Avicenna, Ibn-Sīnā, 981-1037., 20th Century. [© Museum of the Order of St John, 8351,]).
One of the first to acknowledge the possibility of more than one type of diabetes was Ibn-Sīnā in the 8th and 9th centuries. He referred to diabetes as “water wheel” highlighting once again excess urination as a significant symptom. He differentiated this primary type to a secondary one that was the result of another disease. Ibn-Sīnā gave a comprehensive list of symptoms, like the ones mentioned before, but also listed sexual disfunction, mental illness, boils, and gangrene. He treated these symptoms with substances that induced vomiting and recommended horseback riding, lukewarm baths, and fragrant wine. While the success of these treatments cannot be known, his work was influential for centuries onwards.

By the 13th century the symptoms of diabetes had become well established and recognised, even if it wasn’t a very common condition. The ways the condition was diagnosed however began to vary. In the ancient period diabetes was diagnosed with tasting urine or by seeing if there was any sweetness that attracted animals and bugs. This method had mostly fallen out by the 13th century, and instead urine was inspected both as it was and how it affected the elements. This form of examination was known as Uroscopy. To diagnose diabetes, Gilbertus Anglicus wrote in his Compendium of Medicine that one should “receive urine of him that is seke, and kast it on a rede netill at ones whan he hath pist, come agen at the morrow, and if the netille be not dede, it is a token of life, and if it be dede, he shal dy”. Gilbertus made no mention of how he would actually treat diabetes and it was likely that if the patient looked to live, they didn’t require treatment and if they were likely to die then treatment would be of no help.

Uroscopy was ridiculed by Aureoles Theophratus Bombastus von Hoheneim (otherwise known as Paraclesus) in the 15th century who was the first to insist on analysing urine chemically by distillation and other methods. He evaporated the urine of a diabetic patient and obtained a white residue that he mistook for salt. This became a leading way for diagnosis in Switzerland.

Treatment, however, continued to vary on top of this. Donatus Antonius Altomari tried to cure diabetes with sulphur baths and Amatus and Zacitus Lusitanus (no relation) in the 16th century argued that diabetes was caused by an excess of food, sex, and alcohol. Their proposed cure was to intermittently purge patients of all three and preach morality.

Thomas Willis in the 17th century was the one of the first to make the clear distinction between what is now known as Diabetes Mellitus (an umbrella term for diabetes today), and Diabetes Insipidus (a completely separate condition that involves excessive thirst and urination but is not related in any way to glucose or insulin). He reinstated tasting urine as a form of diagnosis and emphasised the sweetness of diabetic urine but never considered that it may contain sugar. He wrote extensively on the condition, referring to the condition as the pissing evil.

At the same time as Willis, a Scottish ex-military surgeon named John Rollo became a consultant to patients with diabetes and one of the leading names in diabetic diagnosis, and treatment. He popularised the term Diabetes Mellitus to differentiate it from standalone symptoms and was one of the first to actively associate cataracts with diabetes. He utilised a urine glucose test developed by Matthew Dobson and wrote about increased sugar in the blood and proposed a protein rich, low carb mostly meat diet that was said to be extremely affective in levelling blood sugar levels (although I’m not sure if the opium he also recommended would have had any impact.)

(Cases of the Diabetes Mellitus [© Wellcome Collection, London]).
The 19th and 20th centuries were an extremely important period for medicine across the board and saw the discovery of diabetes as a hormone deficiency disease. This incited a whole range of different forms of treatment and many cure proclamations. One recommended cure was mixing uranium nitrate and old Bordeaux wine, which apparently would cure both diabetes and obesity, but only if given at an early enough stage. The fifth edition of the US National Dispensatory in 1894 listed no less than 42 cures for diabetes, but evidently none were successful.

One of the most popular forms of treatment was the starvation diet, begun by French physician Apollinaire Bouchardat who noticed that starvation in diabetics during the franco-prussian war reduced glucose in the blood and other symptoms. In his book he advised patients to eat as little as possible. This treatment was popularised by American Frederic Madisson Allen in 1912 who had a worldwide reputation and recommended several days of starvation followed by a diet of undernourishment.

Not everyone agreed with this treatment, and some suggested other diets like John Rollo’s, while others tried all sorts of things including a high carbohydrate high sugar diet that understandably did not work at all. Overall, however, the starvation diet did remain a main form of treatment for many until the discovery of the hormone “insulin” in 1921 by Frederick G Banting, Charles H Best and JJR Macleod at the University of Toronto. They isolated material from the pancreases of dogs, and used it to keep diabetic dogs alive, and in 1922 they gave the first injections to a 14-year-old boy, and almost immediately his blood sugar level began to fall.

In 1923 James B Collip purified the pancreatic extracts to reduce the side effects from treatment. In the same year Banting, Collip and Best were awarded US Patents on Insulin and sold the patents to the University of Toronto for $1 each. Banting said that “insulin [did] not belong to [him], it belong[ed] to the world” and wanted it to be accessible to anyone who needed it. From October 1923, insulin began to be produced on a mass scale.

(Photograph of Frederick Grant Banting with a dog [© Wellcome Collection, London.])
In 1934, the Diabetic Association, now Diabetes UK, was set up by HG Wells and Dr RD Lawrence to improve British access to insulin. Overall worldwide research in the 1940s and 50s led to insulin syringes, and new urine testing methods. The 1960s saw glucose testing strips and the discovery of a purer insulin with less adverse effects. The 1970s witnessed newer portable insulin pumps and glucose metres, as well as the first biosynthetic human insulin. Insulin pens were invented in the late 1980s and from the early 1990s there were new medications for type 2 diabetics such as metformin and acarbose. Research into causes, treatment, monitoring, and a possible cure continues through to today.

Before insulin, there was very little acknowledgement of diabetes within St John Ambulance, as the condition was viewed to be something handled by doctors rather than first responders. Within our first aid journals, there are just four mentions of the condition between 1901 and 1917. One mention was a notice of death, while the other three briefly mentioned diabetes under the listing of symptoms such as thirst and dry mouth. The first mentions of insulin were in the 1927 and 1928 editions of the First Aid Journals and were very brief. Sir Henry Martyn wrote an article In the September 1945 edition, that St John Ambulance needed to do more work on bringing awareness to the condition. Martyn stated that “no instruction whatever is given to those practicing first aid, in spite of the fact that they may meet with such cases at any hour, any day and any place”. It wasn’t until 1954, however, that things notably began to change.

The 1954 first aid journal supplied advice to its readers for the first known time on how to provide first aid to an unconscious diabetic, and in the same year the Annual Sussex Open First Aid Competition also, for the first known time, included a diabetic, in the scenario provided to competitors.

“The ‘incident’ set as a test in the F. A. Competition represented a series of accidents which might take place in the Pinewood or any other studios during the preparation of a set. Bill, a diabetic, having taken his morning before leaving home, should take nourishment at a certain time, and had arranged with Mary, the trolley girl to bring him sandwiches from the canteen. Mary, in her haste following a delay, collides with a heavy standard lamp which falls upon John, who is on the ground preparing to erect a ‘dummy’ steel joist. Bill, meanwhile, owing to the delayed food, has collapsed with Insulin shock behind the set, out of sight. Charlie (not a casualty) goes for help and sends for the ambulance. He returns five minutes later”.

There were 18 injuries overall to be diagnosed and handled correctly with a maximum of 400 marks set for the ‘First Aid’ portion and another maximum of 340 marks for the ‘Diagnosis’. Today you will find a whole section in our first aid manuals on how to provide first aid care to those with diabetes, mostly in reference to hypoglycaemia, and the same is included in St John Ambulance’s first aid courses too.

 

Glossary of Terms:

Diabetes Mellitus– Diabetes Mellitus is the scientific name for diabetes. Diabetes is a disease in which the body’s ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose. There are many types of Diabetes but the two most common are Type One and Type Two.

Gestational Diabetes– A condition in which diabetes can be developed during a pregnancy.

Latent Autoimmune Diabetes in Adults (LADA)– LADA is a type of diabetes that starts in adulthood and slowly gets worse over time and is caused by the pancreas stopping insulin production.

Mature Onset Diabetes of the Young (MODY)– refers to any of the several hereditary forms of diabetes caused by mutations in an autosomal dominant gene disrupting insulin production.

Type One Diabetes– A chronic condition where the pancreas produces little or no insulin.

Type Two Diabetes– A condition results from insufficient production of insulin and insulin resistance, causing high blood sugar.

Type 3C Diabetes– Also known as Pancreatogenic Diabetes, this is when the pancreas is damaged and it stops producing enough insulin for the body as a result.

 

Resources

Adams, J., and Forbes, S., eds., The Syon Abbey Herbal: AD 1517- The Last Monastic Herbal in England (London: AMCD Publishers, 2015).

Diabetes UK

EC1 Echo, no 21 (2023) pg. 10.

Greydanus, D. E., and Merrick, Joav, Diabetes Mellitus, a Medical History Journey (New York: Nova Science Publishers Incorporated, 2016).

Papaspyros, N. S., The History of Diabetes Mellitus (Stuttgart : G. Thieme, 1964).

Porter, R., ed., The Cambridge Illustrated History: Medicine (Cambridge: Cambridge University Press, 2009).

Spencer, M., Introduction to Nursing (London: Wiley-Blackwell, 1981).

Tattersall, R., The Pissing Evil: A Comprehensive History of Diabetes Mellitus (Fife: Swan & Horn, 2017).

Walton, J., Barondess, J. A., and Lock, S., eds., The Oxford Medical Companion (Oxford: Oxford University Press, 1994).

Walton, J., Beeson, P. G., and Scott, R. B., eds., The Oxford Companion to Medicine: Volume I: A-M (Oxford: Oxford University Press, 1986).