Journeying Through Progress in Diabetes Treatment: A Historical Perspective

Preventing and treating lower extremity manifestations of diabetes is a mainstay for many podiatric practitioners. However, in order to understand the future trajectory evaluation and treatment, it behooves clinicians to examine the pathway that led us to the present. In this column, the author takes a look at how diabetes was identified, early interventions, and the evolution in thinking surrounding this condition.

Diabetes mellitus a metabolic disease characterized by hyperglycemia resulting from defects in insulin action or secretion, and has plagued humanity since the beginning of recorded history.¹ There is documentation about patients with excessive thirst and urination as far back as 1500 B.C. in Egyptian papyrus.¹ Around the fifth century B.C., the Indian surgeon Sushruta used the term madhumeha (“honey-like urine”) as a description for diabetes.²

The actual name diabetes was coined during the second century A.D. by a Greco-Roman physician, Aretaeus of Cappadocia, from the Greek word (diabaino) meaning to “to run or go through.”³ His treatment regimen for diabetes reflected the influence of fellow physician Claudius Galen, which favored the balancing of the four humors, typically by bloodletting.⁴ Theriac was a frequently used medication during this period and commonly consisted of viper venom, wine, honey, and cinnamon.⁵ In reality, Theriac offered very little therapeutic value, but remained a popular treatment option until the 18th century.⁵

As the centuries progressed, diabetes appeared in The Canon of Medicine by the influential Persian physician, Avicenna (A.D. 980–1037), who observed the occurrence of gangrene along with abnormal appetite in patients with diabetes and recommended an herbal remedy consisting of a mixture of seeds (lupin beans, fenugreek, and white turmeric).²

Seventeenth and Eighteenth Centuries: The “Sweet Taste of Sickness”

Dr. Thomas Willis, an English anatomist and physician, sipped the urine of patients with diabetes in 1674, noting the sweet taste and added the second word “mellitus,” a Latin word meaning “like honey.”⁶ Dr. Willis acknowledged the stinging and musculo-tendinous contractures of the lower extremities associated with diabetic neuropathy.¹

A century later in 1776, Dr. Matthew Dobson proved through clinical experimentation that patients with diabetes were indeed urinating sugar.⁶ He evaporated the urine of patients with diabetes and only a granulated powder that smelled like sugar remained.⁶ By the end of the 18th century, Dr. John Rollo, an English military physician, published his book An Account of Two Cases of Diabetes Mellitus.⁷ Rollo’s proposal for treatment of diabetes mellitus was a strict diet where animal proteins were favored and dietary sugars severely limited; this method proved successful for patients who were adherent.⁷

Nineteenth Century: Age of Anatomy and Physiology

During the early part of the 19th century it was widely believed that glucose was transported through the lymphatic system into the blood, where it was burned off.⁸ The brilliant French physiologist, Claude Bernard, was skeptical of the prevailing theory and began animal experimentation in the search for scientific clarity.⁸ In 1848, his published work About the Origin of Sugar established the glycogenic action of the liver.⁸ Not long after, around 1869, German pathologist and physiologist Paul Langerhans began studying cross sections of pancreatic tissue under microscopy, discovering cells that would later be recognized as responsible for the production and release of hormones including insulin, which is pivotal for regulating glucose.⁹ The “Islets of Langerhans” were named in his honor after his early death at the age of 40 from tuberculosis.⁹

A major turning point in the understanding of diabetes occurred at the close of the 19th century with the work of German physicians/physiologists, Oskar Minkowski and Joseph Von Mering. Through experimentation on dogs, they validated that the pancreas was responsible for the maintenance of glucose homeostasis and crucial to the pathogenesis of diabetes.¹ This laid the groundwork for the next generation of medical researchers in the twentieth century.

What Can Clinicians Learn From These Cases?

The treatment of diabetes at the dawn of the 20th century revolved around strict monitoring of dietary intake as a means to control blood glucose. An American physician, Dr. Elliot Joslin, wrote a textbook in 1916, The Treatment of Diabetes Mellitus, where he emphasized blood sugar control through scientific menu plans including a low carbohydrate diet.¹⁰ Joslin also felt it was important to empower patients through education to participate in their own care and implemented a system of “wandering diabetes nurses” to help patients in their own homes.¹⁰ For his dedication to the treatment of diabetes, the Joslin Diabetes Foundation was created in 1968.¹¹

Dr. Frederick Banting, a Canadian physician, was inspired after reading an autopsy report by Dr. Moses Barron regarding a patient with a pancreatic duct obstruction where the islet cells were preserved, which led him to ponder: can islet cell secretion be isolated?¹² By 1921, Banting began working with Professor John MacLeod and Dr. Charles Best to extract the secretions from the islet cells, which were later named insulin, Latin for “island.”¹ This groundbreaking discovery was eventually purified for human use and Banting’s team won the Nobel Prize in 1923.¹² During the 1950s, oral antidiabetic drugs (sulfonylureas) were developed to assist in blood glucose control and in 1966 the first pancreatic transplantation was performed on a severely ill patient with Type 1 diabetes.¹ By 1979, the first needle-free insulin system had been developed to provide pain-free administration and now inhaled insulin and oral sprays are available.¹

In Conclusion

Diabetes remains a formidable opponent to modern health care, but seeing how much progress has been made historically offers hope for future therapeutic developments, not just for the condition in general, but for diabetic foot disease as well.

Dr. Miller is a certified wound specialist by the American Board of Wound Management and a Fellow of the American College of Clinical Wound Specialists. She currently serves as the Co-Director of the Limb Salvage Program at the University of Florida, College of Medicine-Jacksonville.

References
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9.    Revie N. Paul Langerhans (1847-1888). Insulin to Innovation. Retrieved July 25, 2022, from https://www.insulintoinnovation.ca/100-lives-of-insulin/paul-langerhans
10.    Dr. Joslin makes first entry in diabetic ledger. 1893. Retrieved July 21, 2022, from https://www.massmoments.org/moment-details/dr-joslin-makes-first-entry-in-diabetic-ledger.html
11.    Vecchio I, Tornali C, Bragazzi NL, Martini M. The discovery of insulin: An important milestone in the history of medicine. Frontiers Endocrinol. 2018; 9:1–8. https://doi.org/10.3389/fendo.2018.00613
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