Feature Article/From Thebes to Toronto From Thebes to Toronto and the 21st Century: An Incredible Journey Lee J. Sanders, DPM Editor’s note: This article is a tran- nature of the ailment, its origin, and script of the address of the American treatment. It is commonly believed Diabetes Association President, that the history of medicine began Health Care and Education, given in with the Greeks, and that prior to the June 2001 at the Association’s 61st time of Hippocrates, there was little Annual Meeting and Scientific that could be called an art of medi- Sessions in Philadelphia, Pa. cine. Nevertheless, for more than 2,000 years before the birth of The story of diabetes mellitus—its dis- Hippocrates, Egyptian physicians had covery, description, and treatment—is been striving to diagnose and treat a remarkable chronicle covering 3,500 disease. Ancient Egypt was the first years of medical history. My civilization known to have an exten- President’s Address, “From Thebes to sive study of medicine and to have left Toronto and the 21st Century” will behind written records of its practices take you on an incredible journey and procedures. through time, highlighting major mile- Across the Nile from Luxor, on the stones in the history of diabetes. West Bank, sits the Necropolis of Regrettably, health care providers Ancient Thebes, a vast land of tombs receive very little instruction in the and temples built to honor the history of medicine. Most medical pharaohs and other nobles. It was and nursing students today have a here, in the vicinity of Thebes, that rather limited, contemporary knowl- German Egyptologist Georg Ebers edge of diabetes. The history of acquired his famous papyrus in 1872. advances in diabetes prior to the dis- Named for him, the Ebers Papyrus is covery of insulin at the University of one of the most famous documents Toronto, in 1921, has been obscured relating to the ancient practice of by the passage of time. Historical medicine. Written about 1550 BCE, concepts of the causes and nature of abundant evidence suggests that it diabetes have either been forgotten or was copied from a series of books never learned. many centuries older. One passage It is my belief that knowledge of dates from the First Dynasty (circa history affords a better understanding 3400 BCE). of contemporary issues and clearer The first reference to diabetes mel- vision as we look to the future. It is litus is attributed to the Ebers my pleasure to share this thrilling Papyrus, which mentions remedies for story with you, and to reveal the ori- the treatment of excessive urination gin of some of the discoveries that (polyuria) (Figure 1). The Ebers have brought us to our current under- Papyrus contains remedies “to elimi- standing of diabetes at the dawn of nate urine which is too plentiful.” The the 21st century. Looking at this ail- following mixture was prescribed for ment over the ages makes one fact the treatment of polyuria: clear: the incidence of diabetes has A measuring glass filled with Water increased dramatically, from an from the Bird pond, Elderberry, uncommon ailment during the period Fibres of the asit plant, Fresh Milk, of antiquity to a worldwide epidemic Beer-Swill, Flower of the expected to affect 300 million people Cucumber, and Green Dates Address correspondence and reprint by the year 2025. Urinary troubles in the adult were requests to: Dr. Lee J. Sanders The story of diabetes unfolds dur- also corrected with rectal injections of Chief, Podiatry Section (N323) ing the Age of Antiquity, where we olive oil, honey, sweet beer, sea salt, Acute Care/Specialty Services begin to see the earliest descriptions of and seeds of the wonderfruit. VA Medical Center the symptoms of diabetes. Ancient Egyptian medicine influenced the 1700 South Lincoln Avenue physicians recorded their observations medical practices of neighboring cul- Lebanon, PA 17042 in an attempt to better understand the tures, including the culture of ancient 56 Diabetes Spectrum Volume 15, Number 1, 2002 Feature Article/Sanders exhilarating revision of medical and scientific concepts. Renaissance physicians and scientists questioned conventional thinking with a renewed spirit of curiosity, objectivi- ty, and experimentation. This period accomplished three things in medi- cine: 1) it shattered authority, 2) it laid the foundation for an accurate knowledge of anatomy, and 3) it demonstrated how the body’s func- tions should be studied intelligently. It was Thomas Willis’s observa- tions of diabetes in 1674 and Matthew Dobson’s experiments in 1776 that conclusively established the diagnosis of diabetes in the presence of sugar in the urine and blood. Diabetes was no longer considered a Figure 1. Commemorative stamp issued by Egypt in 1971 for the World Health rare ailment. Willis referred to dia- Organization’s World Health Day. The stamp features a section of the Ebers betes as the “pissing evil” and noted Papyrus and a portrait of the Egyptian physician Hesy Re. (Scott catalog #864) that in patients with diabetes, “the urine is wonderfully sweet, as if it Greece. Although the Greek physician Hindu physicians Charaka, Susruta, were imbued with honey or sugar.” Hippocrates, “the father of medi- and Vaghbata described polyuria and He claimed that diabetes was primari- cine,” did not specifically mention glycosuria. They noted the attraction ly a disease of the blood and not the diabetes in his writings, there are of flies and ants to the urine of those kidneys. Willis proposed that the accounts in the Hippocratic writings affected by this ailment. sweetness first appeared in the blood that are consistent with the signs and The practice of medicine in the and was later found in the urine. symptoms of diabetes. There are refer- Middle Ages (350 CE to about 1450 Dobson provided experimental evi- ences to excessive urinary flow with CE) was fundamentally a restatement dence that people with diabetes elimi- wasting of the body. Hippocrates pro- and acceptance of Greco-Roman nate sugar in their urine. He gently moted the concept of preventive medi- teachings. Arabian physicians trans- heated two quarts of urine to dryness. cine. He stressed the influence of diet, lated the works of Hippocrates and The remaining residue was a whitish exercise, and lifestyle on health. Galen and offered minor modifica- cake, which, Dobson wrote, “was Galen and Aretaeus were disciples tions. of Hippocrates. Galen, the most influ- Two prominent medieval physi- ential medical writer of all time, dis- cians who contributed to the knowl- cussed diabetes in a number of his edge of diabetes in the 11th and 12th works. He described the condition as centuries were Avicenna and Moses rare, as he had only seen two cases. Maimonides. Maimonides was a He referred to the ailment as “diar- renowned medieval physician, rabbi, rhea of the urine” and “the thirsty and philosopher. Although Galen disease.” wrote that diabetes was rare and that Aretaeus, a contemporary of he had seen only two cases of this ill- Galen, provided the first accurate ness, Maimonides claimed to have description of the symptoms of dia- seen more than 20 cases. He pro- betes (Figure 2). He was the first to posed that diabetes was caused by use the term “diabetes” in connection the sweet waters of the Nile and the with this ailment. The term diabetes prevailing heat that spreads over the was derived from the Greek word for kidneys. siphon. Aretaeus’ classic description No further progress was made in begins “Diabetes is a wonderful affec- the understanding of diabetes until tion, not very frequent among men, the 16th century, when the being a melting down of the flesh and Renaissance physician Paracelsus limbs into urine…” challenged the medical doctrine of The ancient Hindus were the first the time and attempted to reform Figure 2. This stamp issued by to coin the term “honey urine,” a medical thinking. Osler described Transkei in 1990 features the image thousand years before the first Paracelsus as the “Luther of medi- of Aretaeus and a brief section of his Europeans recognized the sweet taste cine,” the embodiment of the spirit description of diabetes. (Scott catalog of urine in patients with diabetes. The of revolt. In medicine, there was an #235) 57 Diabetes Spectrum Volume 15, Number 1, 2002 Feature Article/From Thebes to Toronto granulated and broke easily between At the close of the 19th century, recruited a young biochemist, James the fingers; it smelled sweet like Oscar Minkowski demonstrated con- Bertram Collip, to assist Banting and brown sugar, neither could it be dis- clusively that removal of the pancreas Best in obtaining a pancreatic extract. tinguished from sugar, except that the from a dog results in the production An article written in 1920 by sweetness left a slight sense of cool- of fatal diabetes. This was the turning Moses Barron stimulated Banting’s ness on the palate.” Dobson detailed point in determining the endocrine research interests. Barron described his findings in a paper presented to function of the pancreas. the rare case of a pancreatic stone that the medical society of London in The discovery and isolation of blocked the main pancreatic duct. The 1776. Prior to presentation of his insulin at the University of Toronto in blockage resulted in degeneration of findings, Dobson consulted with 1921–22 was one of the greatest the acinar glandular cells but not the William Cullen, one of Britain’s fore- events in the history of medicine. islet cells. Banting wrote the following most clinicians, consultants, and edu- Insulin therapy would soon commute words in his research notebook cators. the death sentence associated with the (Figure 3): It was Cullen who was the first to diagnosis of type 1 diabetes.