Type 1 Diabetes

Aretaeus of Cappadocia (30–90 A.D.), living under the emperor Nero, and writing in Ionian Greek, was the second to describe diabetes, and the first known to have called it by the name (to run through; a siphon). In a passage translated by Schnée", Aretaeus outlines some of the principal symptoms, the progressive course, and the fatal prognosis. He anticipates modern conceptions of a failure of assimilation, conversion of tissue into urinary products, and possible origin of some cases in acute infections. He was retrograde in treatment, for he advised a non-irritating diet of milk and carbohydrates, and hiera, nardum, mastix, and theriak (opium?sugar?) as drugs. He is commonly credited with being the first to regard diabetes as a disease of the stomach; but his vague notion of a disorder akin to ascites hardly entitles him to a claim upon this false idea which was productive of so much truth in the period from Rollo to Cantani.

“Diabetes is a strange disease, which fortunately is not very frequent. It consists in the flesh and bones running together into urine. It is like dropsy in that the the cause of both is moisture and coldness, but in diabetes the moisture escapes through the kidneys and bladder. The patients urinate unceasingly; the urine keeps running like a rivulet. The illness develops very slowly. Its final outcome is death. The emaciation increases very rapidly, so that the existence of the patients is a sad and painful one. The patients are tortured by an unquenchable thirst; they never cease drinking and urinating, and the quantity of the urine ex ceeds that of the liquid imbibed. Neither is there any use in trying to prevent the patient from urinating and from drinking; for if he abstains only a short time from drinking his mouth becomes parched, and he feels as if a consuming fire were raging in his bowels. The patient is tortured in a terrible manner by thirst. If he re tains the urine, the hips, loins, and testicles begin to swell; the swelling subsides as soon as he passes the urine. When the illness begins, the mouth begins to be parched, and the saliva is white and frothy. A sensation of heat and cold extends down into the bladder as the illness progresses; and as it progresses still more there is a consuming heat in the bowels. The integuments of the abdomen become wrinkled, and the whole body wastes away. The secretion of the urine becomes more copious, and the thirst increases more and more. The disease was called diabetes, as though it were a siphon, because it converts the human body into a pipe for the transflux of liquid humors. Now, since the patient goes on drinking and urinating, while only the smallest portion of what he drinks is assimilated by the body, life naturally cannot be preserved very long, for a portion of the flesh also is excreted through the urine. The cause of the disease may be that some malignity has been left in the system by some acute malady, which afterward is developed into this disease. It is possible also that it is caused by a poison con tained in the kidneys or bladder, or by the bite of the thirst-adder or dipsas.”

"Aretaeus’ writings were unknown in Europe until 1552. His aim in treating what was clearly type 1 diabetes was to overcome the  diabetes: the intense thirst, and to this end he began with a purge and followed it with a variety of mixtures to soothe the stomach."

Diabetes: The Biography

"In the year 1777 ... I saw a case of the Diabetes Mellitus in a weaver at Edinburgh. He had been at least four months in the Royal Infirmary without having derived any advantage, and was chiedy under the care of the late Dr. Hope, Professor of Botany. When the patient was discharged, a Mr. Johnstone, then a Student of Physic, and myself, detained him a few days, and paid his expenses, in order to bleed him, and obtain some of his urine, so as to ascertain the appearances and spontaneous changes. I well remember that the blood and urine exhibited the appearances discribed by Dr. Dobson; but the papers, and a portion of the saccharine extract which I carried with me abroad, were lost in the hurricane at Barbados in 1789."

Rollo, with the aid of Cruickshank, carried out laboratory studies with his patients to ascertain the results of treatment and to elucidate the nature of diabetes. The fluid intake, urine output and the body weight were determined. The urine was tasted to indicate the presence of sugar and subjected to experiments before and after evaporation to determine its chemical composition and content of sugar. At the beginning of treatment when Captain Meredith was passing up to twelve quarts of urine in twenty-four hours, the following notes were made: 

"Mr. Cruickshank took 36 ounces troy weight of urine voided today, and it yielded by evaporation three ounces and one drachm of saccharine extract, of the appearance of molasses, but thicker, having nearly the consistence of wax, and somewhat tenacious. If, therefore, the whole of the day's urine had been evaporated it would have yielded about 29 ounces troy weight, an astonishing quantity to be formed and seperated form the system. By standing in the air it became moist, and of nearly the consistence, smell and appearance of treacle." 

"Treating some of this extract with the nitrous acid, he procured the saccarine or oxalic acid; and with a smaller proportion of the acid it produced a substance, which in resemblance, and smell, could not be distinguished from honey."

Diabetes Its Medical and Cultural History

"From that period I had not met with a case of Diabetes, although I had observed an extensive range of disease in America, the West Indies, and in England, until 1796." "Captain Meredith, of the Royal Artillery, being an acquaintance. I had seen him very frequently, previous to his going on camp duty in 1794, but then he had no disease; however, he always had impressed me, from his being a large corpulent person, with the idea that he was not unlikely to fall into disease. (Editor: Another instance of Rollo's clinical acuteness.)" "On the 12th of June, 1796, he visited me, and though I was at once struck with the diminution of his size, yet, at the same time, the colour of his face being ruddy, I received no impression, otherwise than of his being in health: a moment's conversation, however, convinced me of the contrary ...... 

"He complained of great thirst and a keenness of appetite; his skin was hot, dry and parched; and his pulse small and quick. He told me his complaints had been attributed to an old disease, and a liver affection. The thirst, dry skin, and quick pulse, marking a febrile state, depending probably on some local circumstance, and connecting these with the keenness of appetite, Diabetes immediately suggested itself to me. I enquired into the state of his urine, which I found in quantity and colour to be characteristic of the disease; and was at the same time much surprised, that for the two or three months he had been under the care of a Physician and Surgeon, the circumstance of the increased urine had not been known to them. The patient told me, as he drank so much, the quantity of urine had appeared to him a necessary consequence; and of course never having been asked about it, he gave no information. I directed him to keep the urine he next passed, and, on examination, it was found to be sweet; in consequence of which the disease became sufficiently ascertained." 

At another point in the case history, Rollo states that Captain Meredith was 34 years of age and was 71 3/4 inches tall. At the time of beginning of the special treatment, the symptoms of diabetes had been present seven months or more and his weight had fallen from 232 to 162 pounds. A view held by some at that time was that diabetes was a primary affection of the kidneys. However, Rollo developed the idea that the disease was "a primary and peculiar affection" of the stomach in which, due to some morbid changes in "the natural powers of digestion and assimilation," sugar or saccharine material was formed in that organ, chiefly from vegetable matter. It was on this basis that he advocated the use of an animal diet together with certain medication designed to quiet the overactive stomach and to diminish the appetite. 

Following initial bloodlettings, Rollo's treatment of Captain Meredith was as follows: 

"1st. The diet to consist of animal food principally, and to be thus regulated: 

Breakfast. One and a half pint of milk and half a pint of lime-water, mixed together; and bread and butter. 

Noon. Plain blood-puddings, made of blood and suet only. 

Dinner. Game, or old meats, which have been long kept; and as far as the stomach may bear, fat and rancid old meats, as pork. To eat in moderation. 

Supper. The same as breakfast." 

"2dly. A drachm of kali sulphuratum to be dissolved in four quarts of water which has been boiled, and to be used for daily drink. No other article whatever, either eatable or drinkable, to be allowed, than what has been stated." 

"3dly. The skin to be annointed with hog's lard every morning. Flannel to be worn next the skin. The gentlest exercise to be only permitted; but confinement to be preferred." 

"4thly. A draught at bed-time of twenty drops of tartarized antimonial wine and twenty-five of tincture of opium; and the quantities to be gradually increased. In reserve, as substances diminishing action, tobacco and foxglove. " 

"5thly. An ulceration, about the size of half a crown, to be produced and maintained externally, and immediately opposite to each kidney. And, 

"6thly. A pill of equal parts aloes and soap, to keep the bowels regularly open."

Therapy 

A special diabetic diet was undoubtedly one of the foremost therapeutic measures, even before the age of insulin. Even before it was recognized that diabetes was a disorder of carbohydrate metabolism, various kinds of diet had been recommended. A change to a diet decided purely pragmatically, which was nevertheless very effective, did not come until JOHN ROLLO (d. 1809), a Scottish physician, who, in 1797, had achieved good results with a meat diet, made his recommendation (MARBLE; ANDERSON; BECKENDORF). He gave a particularly detailed account  The History of Diabetes mellitus 85 of the case of Captain MEREDITH of the Royal Artillery, who became diabetic at the age of 34, and who was very obviously overweight. His diet consisted of a breakfast and supper of milk mixed with lime-water and bread and butter, while his dinner consisted of pudding made of fat and blood and mature, preferably rank pork. In this way he had - without being conscious of it - excluded carbohydrates almost entirely from the diet. The patient of course lost a great deal of weight and felt extremely well. 

A second patient was less cooperative and therefore died at the age of 57, 19 months after treatment was begun, mainly - as ROLLO pointed out - because during his last three months he indulged in such things as apple pudding, sugar in his tea, and wine. 

The "meat diet" was used well into the 19th century, although gradually it was considered wiser not to cut out all carbohydrates, and patients had a certain amount of carbohydrate added to their diet, even though that caused some glycosuria. This kind of diet was initiated in the middle of the 19th century, mainly by ADOLF NIKOLAUS VON DURING (1820-1882) and RUDOLF EDUARD KULZ (1845-1895). The latter even distinguished between harmful and harmless carbohydrates and found that levulose, inulin, inosit, mannite, and lactose, as well as some root vegetables like celery, comfrey, etc. caused no deterioration of the metabolic condition. But it remains true that many specialists did recommend a carbohydrate-free diet with a lot of meat and fat (DICKINSON; PAVY; SEEGEN; R. SCHUMACHER, STEPP). 

4th May, 1797- I SEND you an extract of the case of Walker, with Dr. Hope's permission, and you may do with it whatever you please. The effects of the animal diet on the quantity and quality of the urine are perfectly evident, though the case could not be carried to an absolute termination, from the impatience and instability of the patient. In Hospitals, where patients three three or four times in the day every person about them eating vegetables, a trial of an entire diet of animal food can hardly be expected.

James Walker, a field-labourer, was admitted by Dr. Hope into the Clinical Ward, with a confirmed Diabetes, on the 1st November, 1796. 

"His appetite is voracious, and his thirst so urgent, as to make him defire from ten to fixteen quarts in twenty-four hours. His urine is praeternaturally copious, and he has a frequent inclination to pass it. It is limpid, of a light green colour, and having a slightest sweet taste. He is much emaciated ; and his feet and ankles swell towards evening. Pulse 96. Skin parched and rough. Body costive. 

He recollects, on a frosty morning in December 1795, having slept fome hours in an open cart, On the May following the above symptoms appeared, and have increased ever since. He has feveral times been the object of medical treatment; but without permanent relief. 

• 2d. Milk daily, and as much drink as he chooses. 

• 3d. Urine 22 pounds, Ingefta 20 pounds.. AtL 153

• 4d. Urine 13 pounds. Ingefta 17 pounds. The urine becomes turbid on the addition of lime water; when evaporated it affords an extract like molasses, which is sweet to the taste. This matter mixed with lime, exhales the odour of ammonia. 

• From this day to the 29th December, he remained nearly in the same state, the quantity of urine fluctuating between 12 and 18 pounds in 24 hours. During this interval he took some ferrum vitriolatum in the form of pills; ufed the cold shower bath, and took occassionally fome emetics and laxatives ; —the stomach being at times deranged, and the coflivenefs very obflinate. Under this treatment he feemed to get a little stronger, but without any important change in the general symptoms of the disease. It was agreed to try the effects of animal food, as lately given with success by Dr. Rollo at Woolwich, an account of which was tranfmitted by Dr. Woollcombe to Mr. Marcet. 

• December 29th, Dr. Hope gave the following report. Ingesta 17 pounds; urine 13 pounds. Five pounds of this urine have afforded 5ounces of a thick saccharine extract. He has had for a month, an unpleasant sense of burning heat in the soles of his feet during the night. He is directed to abstain from vegetable food in every shape. To have two eggs for breakfast. Boiled meat and fleaks alternately for dinner. Eggs, or cheefe for fopper. For drink eight pounds of weak beef tea, and two pounds of weak peppermint water. 

• 30th December. Solid ingested about two pounds ; drink ten pounds ; urine nine pounds. Let him have two pounds of flesh meat for dinner; half a pound of cheese for supper; and three eggs for breakfast—drink as before, Ingefta (drink, and food) ten pounds ; urine five pounds, which exhales an unusually strong urinous smell. Had a partial sweat over the trunk and head in the night. Mouth moist; no sourness. of stomach. 

• January 1st, 1797- Solid ingesta as usual ; drink nine pounds ; urine eight pounds, more limpid than yeflerday, and has a sharp acid odour. The breath has the fame smell . The colour of the urine, however, is not changed, on addition of syrup of violets. There is slight headache and sickness. The tongue appears much cleaner than usual. Has had a stool. Contin. diaeta animalis. 

• January 2d. Solid ingefta the fame; drink eight pounds; urine fix pounds. No flcknefs or hcadach ; tongue clear; the burning heat of the feet as before. One Joofe ftool. Contin. 

• 3d. Drink 10 pounds; urine 7 1 pounds, of a deeper yellow than formerly; tongue natural. Contin. 

• 4th. Drink ten pounds; urine feven pounds. Contin. 

• 5th. Drink nine pounds ; urine 6{ pounds, more yellow, with a peculiar (not urinous) odour. Contin. 

• 6th. No report, as laft night he went out, returned to the ward drunk, fo that his urine could not be meafured. 

• 7th. Drink 7 pounds ; urine 6 pounds, having the same peculiar smell, 

• 8th. Drink 7 pounds; urine 6 pounds; body coftive. Contin. diaeta animalis. Sum: ftatim pil. rhoei. comp. ^ l'et iterum eras mane. 

• 9th. 156 Qtfa Drink iix pounds ; urine four pounds ; a copious ftool this morning; ftrength not changed fince he began the animal food. Contin. et habeat aq. menth. piper, lbiv pro potu. minuatur quantitas decocti carnis ad lbiv. 

• 10th. Solid food as formerly ; drink feven pounds ; urine five pounds ; no flool. Sum : flatim pil. rhcei. comp. B 1. 

• llth. Drink fix pounds ; urine four pounds ; three llools this morning. Contin. diaeta animalis, 

• 12th. Drink fix pounds ; urine four pounds ; two ftools—he thinks his ftrength is fomewhat impaired within thefe two or three days. Adeat eras mane balneum frigidum. Drink feven pounds ; urine five pounds ; bore, the bath well. Contin, 1 4th. Drink eight pounds; urine fix pounds. Contin* 

• 1 5th. Drink eight pounds ; urine fix pounds. 

• l6tk Solid food as before; drink eight pounds; urine fix pounds, of a light ftraw colour, and with the peculiar fmell it has had for fome time. The urine of the 14th being evaporated, afforded matter of confiderable confiftence, with a ftrong faline, but fcarcely perceptible fweetifh tafte. 

• 17th. Drink eight pounds ; urine fix pounds ; thinks he is weaker. 

• 18th. Drink eight pounds; urine 5| pounds. Contin, IQth and 10th. Drink each day eight pounds ; urine fix pounds. Contin. 1\Ji January. Drink feven pounds ; urine five pounds. He has left the Infirmary to-day, by his own defire, to return to the country." 

• 4th May. Dr. Hope told me a few days ago, that he had just then. received a letter from Walker, who says that since he left the Infirmary he has become weaker; and there is some expectation of his returning foon to the Hospital to resume his treatment. But it is doubtful whether when he was in the Clinical Ward he observed strictly the diet preferred. At least he was accustomed to go about freely; and the nurse told me repeatedly, that she suspected he did not entirely abstain from indulgencies of eating and drinking out of the house.